DOS CARC EOB Code EOB Description Effective Date ... - Alabama · EOB Code EOB Description Checkwrite Effective Date Checkwrite End Date DOS Effective DOS End CARC CODE CARC DESCRIPTION

EOB Code EOB DescriptionCheckwrite Effective Date

Checkwrite End Date

DOS Effective DOS End

CARC CODE CARC DESCRIPTION RARC CODE RARC Description

0201INVALID PAY-TO PROVIDER NUMBER 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N280

MISSING/INCOMPLETE/INVALID PAY-TO PROVIDER PRIMARY IDENTIFIER.

0203 RECIPIENT I.D. NUMBER MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid patient identifier.

0204 RECIPIENT ID - OLD FORMAT 20150715 22991231 19000101 22991231 16



0206PRESCRIBING PROVIDER NUMBER NOT IN VALID FORMAT 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID PRESCRIBING PROVIDER IDENTIFIER.

0207 INVALID/MISSING BIRTH WEIGHT 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N207 MISSING/INCOMPLETE/INVALID WEIGHT.

0208 PREGNANCY INDICATOR INVALID 20150725 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.


Checkwrite End Date



0209

AT LEAST ONE OF THE SUBMITTED DELIVERIES IS MISSING A VALID BIRTHWEIGHT 20170101 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N207 MISSING/INCOMPLETE/INVALID WEIGHT.

0210BRAND MEDICALLY NECESSARY INDICATOR INVALID 20150715 22991231 19000101 22991231 16


INCOMPLETE/INVALID CONTRACT INDICATOR.

0211 INVALID REFILL INDICATOR VALUE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid prescription quantity.

0212 MISSING PRESCRIPTION NUMBER 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid prescription number.

0213 DATE PRESCRIBED IS MISSING 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID PRESCRIBING DATE.


Checkwrite End Date



0214 DATE PRESCRIBED IS INVALID 20150715 22991231 19000101 22991231 16



0215 DATE DISPENSED IS MISSING 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID DISPENSED DATE.

0216 DATE DISPENSED IS INVALID 20150715 22991231 19000101 22991231 16



0217 MISSING DRUG CODE 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. M119

Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).

0218 INVALID DRUG CODE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0219 QUANTITY DISPENSED IS MISSING 20150715 22991231 19000101 22991231 16



0220 QUANTITY DISPENSED IS INVALID 20150715 22991231 19000101 22991231 16



0221 MISSING DAYS SUPPLY 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid days or units of service.

0222 ESTIMATED DAYS SUPPLY INVALID 20150715 22991231 19000101 22991231 16



0223 MISSING DIAGNOSIS INDICATOR 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid diagnosis or condition.


Checkwrite End Date



0224DIAGNOSIS TREATMENT INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0225REFERRING PROVIDER - INVALID FORMAT 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY IDENTIFIER.

0226ANESTHESIA CLAIMS REQUIRE REFERRING PROVIDER 20150715 22991231 19000101 22991231 16



0227THIRD PARTY PAYMENT AMOUNT INVALID 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. M79 Missing/incomplete/invalid charge.

0233 UNITS OF SERVICE MISSING 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0234 PROCEDURE CODE MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid procedure code(s).

0235PROCEDURE CODE NOT IN VALID FORMAT 20150715 22991231 19000101 22991231 16



0236

NO PROCEDURE FOR REVENUE CODE; MEDICAID HAS NO PAYMENT LIABILITY FOR THIS LINE 20150715 22991231 19000101 22991231 16



0239DETAIL TO DATE OF SERVICE IS MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid "to" date(s) of service.

0240 THE DETAIL "TO" DATE IS INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0242SECONDARY DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid other diagnosis.

0243 MISSING MEDICARE PAID DATE 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID ADJUDICATION OR PAYMENT DATE.

0244 THIRD DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16



0246FOURTH DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16



0247MAXIMUM NUMBER OF CLAIM DETAILS EXCEEDED 20160501 22991231 19000101 22991231 273 Coverage/program guidelines were exceeded. N362

THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE MAXIMUM.

0248PLACE OF SERVICE IS MISSING OR BLANK 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid/inappropriate place of service.


Checkwrite End Date



0249 PLACE OF SERVICE IS INVALID 20150715 22991231 19000101 22991231 16



0250 CLAIM HAS NO DETAILS 20150715 22991231 19000101 22991231 16


INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE.

0251FIRST MODIFIER INVALID FOR DATE OF SERVICE 20150715 22991231 19000101 22991231 182 Procedure modifier was invalid on the date of service.

0252SECOND MODIFIER INVALID FOR DATE OF SERVICE 20150715 22991231 19000101 22991231 182 Procedure modifier was invalid on the date of service.

0253THIRD MODIFIER INVALID FOR DATE OF SERVICE 20150715 22991231 19000101 22991231 182 Procedure modifier was invalid on the date of service.

0255PATIENT RSN FOR VISIT REQ ON OUTPATIENT HOSP CLAIM 20150715 22991231 19000101 22991231 16



0256ADMIT DIAGNOSIS INVALID ON OUTPATIENT HOSP CLAIM 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0257PATIENT RSN FOR VISIT INVALID ON INPATIENT CLAIM 20150715 22991231 19000101 22991231 16



0258 MISSING DIAGNOSIS CODE 20150715 22991231 19000101 22991231 16



0260UNITS OF SERVICE NOT IN VALID FORMAT 20150715 22991231 19000101 22991231 16



0261 MISSING TOOTH NUMBER 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid tooth number/letter.

0262 INVALID TOOTH NUMBER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0263 INVALID TOOTH SURFACE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid tooth surface information.

0264DETAIL FROM DATE OF SERVICE IS MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid "from" date(s) of service.

0265DETAIL FROM DATE OF SERVICE IS INVALID 20150715 22991231 19000101 22991231 16



0266 MISSING TOOTH SURFACE 20150715 22991231 19000101 22991231 16



0267DUPLICATE TOOTH SURFACES SUBMITTED ON DETAIL 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0268 BILLED AMOUNT INVALID 20150715 22991231 19000101 22991231 16


0269DETAIL BILLED AMOUNT MISSING OR INVALID FORMAT 20150715 22991231 19000101 22991231 16


0270 MISSING TOTAL CLAIM CHARGE 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. M54 Missing/incomplete/invalid total charges.

0271 INVALID TOTAL CLAIM CHARGE 20150715 22991231 19000101 22991231 16


0272PRIMARY DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA63

Missing/incomplete/invalid principal diagnosis.


Checkwrite End Date



0273 TYPE OF BILL MISSING 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA30 Missing/incomplete/invalid type of bill.

0274 TYPE OF BILL CODE INVALID 20150715 22991231 19000101 22991231 16


0275 ADMIT DATE MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid admission date.

0276 ADMIT DATE INVALID 20150715 22991231 19000101 22991231 16



0277 INVALID ADMISSION HOUR 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid admission hour.


Checkwrite End Date



0278 ADMIT TYPE MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid admission type.

0279 INVALID TYPE OF ADMISSION 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid admission type.

0280 PATIENT STATUS IS MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid patient status.

0281 PATIENT STATUS IS INVALID 20150715 22991231 19000101 22991231 16



0282 MISSING COVERED DAYS 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid number of covered days during the billing period.


Checkwrite End Date



0283 COVERED DAYS INVALID 20150715 22991231 19000101 22991231 16



0284PRIMARY CONDITION CODE INVALID 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid condition code.

0285SECOND CONDITON CODE INVALID 20150715 22991231 19000101 22991231 16



0286 THIRD CONDITION CODE INVALID 20150715 22991231 19000101 22991231 16



0287FOURTH CONDITION CODE INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0288 FIFTH CONDITION CODE INVALID 20150715 22991231 19000101 22991231 16



0289 SIXTH CONDITION CODE INVALID 20150715 22991231 19000101 22991231 16



0290SEVENTH CONDITION CODE INVALID 20150715 22991231 19000101 22991231 16



0295DATE FOR PRIMARY OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OCCURRENCE DATE(S).

0296DATE FOR PRIMARY OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0297DATE FOR SECOND OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16



0298DATE FOR SECOND OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16



0299DATE FOR THIRD OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16



0300DATE FOR THIRD OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16



0301DATE FOR FOURTH OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0302DATE FOR FOURTH OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16



0304CLAIM HAS TOO MANY DIAGNOSIS SEQUENCES 20170101 22991231 19000101 22991231 252

An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). N485 Missing Physical Therapy Certification.

0305DIAGNOSIS SEQUENCE CONTAINS AN INVALID CHARACTER 20170101 22991231 19000101 22991231 16



0306BOTH ICD-9 AND ICD-10 CODES NOT ALLOWED 20150715 22991231 19000101 22991231 236

This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. N657

This should be billed with the appropriate code for these services.

0307BOTH ICD-9 AND ICD-10 PROC CODES NOT ALLOWED 20150715 22991231 19000101 22991231 236



0308BOTH ICD-9 AND ICD-10 DIAG CODES NOT ALLOWED 20150715 22991231 19000101 22991231 236



0309ICD PROCEDURE VERSION INVALID FOR COMPLIANCE DATES 20150715 22991231 19000101 22991231 181 Procedure code was invalid on the date of service.

0310ICD DIAGNOSIS VERSION INVALID FOR COMPLIANCE DATES 20150715 22991231 19000101 22991231 146 Diagnosis was invalid for the date(s) of service reported.


Checkwrite End Date



0311PRIMARY DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0312SECOND DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0313THIRD DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0314FOURTH DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0315FIFTH DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0316SIXTH DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0317SEVENTH DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0318EIGHTH DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0319NINTH DIAGNOSIS PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16



0320DIAGNOSIS 10-24 PRESENT ON ADMISSION INDICATOR INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0330 DTP DATE INVALID 20150715 22991231 19000101 22991231 16



0331DATE LAST MENSTRUAL PERIOD MISSING OR IN FUTURE 20150715 22991231 19000101 22991231 16



0332DATE FIRST PRENATAL VISIT MISSING OR IN FUTURE 20150715 22991231 19000101 22991231 16



0339 REVENUE CODE IS MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid revenue code(s).

0340 REVENUE CODE IS INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0350

THE NUMBER OF DETAILS IS NOT EQUAL TO THE SUBMITTED DETAIL COUNT. 20150715 22991231 19000101 22991231 16



0355 FIFTH DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16



0356 SIXTH DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16



0357SEVENTH DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16



0358 EIGHTH DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0359 NINTH DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16



0360 ADMITTING DIAGNOSIS MISSING 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid admitting diagnosis.

0361ADMITTING DIAGNOSIS CODE INVALID 20150715 22991231 19000101 22991231 16



0363PRINCIPAL ICD PROCEDURE CODE IS INVALID 20150715 22991231 19000101 22991231 16



0364PRINCIPAL ICD PROCEDURE DATE MISSING 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE DATE.


Checkwrite End Date



0365PRINCIPAL ICD PROCEDURE DATE INVALID 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE DATE.

0366FIRST OTHER PROCEDURE CODE INVALID 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OTHER PROCEDURE DATE(S).

0367FIRST OTHER ICD PROCEDURE DATE MISSING 20150715 22991231 19000101 22991231 16



0368FIRST OTHER ICD PROCEDURE DATE INVALID 20150715 22991231 19000101 22991231 16



0369SECOND OTHER PROCEDURE CODE INVALID 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OTHER PROCEDURE CODE(S)


Checkwrite End Date



0370SECOND OTHER ICD PROCEDURE DATE MISSING 20150715 22991231 19000101 22991231 16



0371SECOND OTHER ICD PROCEDURE DATE INVALID 20150715 22991231 19000101 22991231 16



0372THIRD OTHER PROCEDURE CODE INVALID 20150715 22991231 19000101 22991231 16



0373THIRD OTHER ICD PROCEDURE DATE MISSING 20150715 22991231 19000101 22991231 16



0374THIRD OTHER ICD PROCEDURE DATE INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0375FOURTH OTHER PROCEDURE CODE INVALID 20150715 22991231 19000101 22991231 16



0376FOURTH OTHER ICD PROCEDURE DATE MISSING 20150715 22991231 19000101 22991231 16



0377FOURTH OTHER ICD PROCEDURE DATE INVALID 20150715 22991231 19000101 22991231 16



0378FIFTH OTHER PROCEDURE CODE INVALID 20150715 22991231 19000101 22991231 16



0379FIFTH OTHER ICD PROCEDURE DATE MISSING 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0380FIFTH OTHER ICD PROCEDURE DATE INVALID 20150715 22991231 19000101 22991231 16



0381ATTENDING PHYSICIAN PROVIDER NUMBER MISSING 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER PRIMARY IDENTIFIER.

0395HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING 20150715 22991231 19000101 22991231 16



0396HEADER STATEMENT COVERS PERIOD "FROM" DATE INVALID 20150715 22991231 19000101 22991231 16



0397HEADER STMT COVERS PERIOD "THROUGH" DATE MISSING 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0398STATEMENT COVERS PERIOD "THROUGH" DATE INVALID 20150715 22991231 19000101 22991231 16



0400DETAIL UNITS OF SERVICE MUST BE GREATER THAN ZERO 20150715 22991231 19000101 22991231 16



0411DATE FOR FIFTH OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16



0412DATE FOR FIFTH OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16



0413DATE FOR SIXTH OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0414DATE FOR SIXTH OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16



0415DATE FOR SEVENTH OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16



0416DATE FOR SEVENTH OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16



0417DATE FOR EIGHTH OCCURRENCE CODE MISSING 20150715 22991231 19000101 22991231 16



0418DATE FOR EIGHTH OCCURRENCE CODE INVALID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0433MEDICARE DEDUCTIBLE AMOUNT INVALID 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid value code(s) or amount(s).

0434MEDICARE COINSURANCE AMOUNT INVALID 20150715 22991231 19000101 22991231 16



0436TOTAL MEDICARE ALLOWED AMOUNT INVALID 20150715 22991231 19000101 22991231 16



0438 COPAY AMOUNT INVALID 20150715 22991231 19000101 22991231 16



0450 INVALID QUADRANT 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid oral cavity designation code.


Checkwrite End Date



0455DENTAL PREDETERMINATION OF BENEFITS NOT ALLOWED 20150715 22991231 19000101 22991231 96

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N30 Patient ineligible for this service.

0456INVALID PROCEDURE TYPE ACC. TO PROCEDURE QUALIFIER 20150715 22991231 19000101 22991231 16



0457INVALID PRINCIPAL/OTHER PROCEDURE TYPE 20150715 22991231 19000101 22991231 16



0458

THE DIAGNOSIS CODE IN SEQUENCE 10-24 IS IN AN INVALID FORMAT 20150715 22991231 19000101 22991231 16



0465DATE FOR OCCURRENCE CODE 9-24 MISSING 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0466DATE FOR OCCURRENCE CODE 9-24 INVALID 20150715 22991231 19000101 22991231 16



0471 CONDITION CODE 8-24 INVALID 20150715 22991231 19000101 22991231 16



0473 ICD PROCEDURE 7-24 INVALID 20150715 22991231 19000101 22991231 16



0474ICD PROCEDURE 7-24 OR DATE MISSING 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S).

0475ICD PROCEDURE 7-24 DATE INVALID 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S).


Checkwrite End Date



0500DATE PRESCRIBED AFTER BILLING DATE 20150715 22991231 19000101 22991231 16



0502DATE DISPENSED EARLIER THAN DATE PRESCRIBED 20150715 22991231 19000101 22991231 16



0503DATE DISPENSED AFTER BILLING DATE 20150715 22991231 19000101 22991231 110 BILLING DATE PREDATES SERVICE DATE.

0505NO PAYMENT MADE-TPL IS MORE THAN THE ALLOWED AMOUNT. 20150715 22991231 19000101 22991231 16



0507FIRST DATE OF SERV GREATER THAN LAST DATE OF SERV 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid beginning and ending dates of the period billed.

0508TOTAL CHARGE DOES NOT EQUAL THE SUM OF ALL DETAILS 20150715 22991231 19000101 22991231 16


0512SERVICE(S) PAST THE MAXIMUM MEDICAID FILING LIMIT 20150715 22991231 19000101 22991231 29 The time limit for filing has expired.


Checkwrite End Date



0513NAME ON CLAIM MUST MATCH NAME ON FILE 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA36 Missing/incomplete/invalid patient name.

0514DATE RECEIVED FOR PROCESSING-PRIOR TO DATE OF SERV 20150715 22991231 19000101 22991231 16



0519ADMIT DATE GREATER THAN FIRST DATE OF SERVICE 20150715 22991231 19000101 22991231 16



0526DETAIL DATES NOT WITHIN HEADER DATES 20150715 22991231 19000101 22991231 16



0527DETAIL FROM DATE OF SERVICE IS AFTER ICN DATE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0537HDR FROM DATE OF SERVICE > HDR TO DATE OF SERVICE 20150715 22991231 19000101 22991231 16



0555SERVICE(S) PAST THE MAXIMUM MEDICAID FILING LIMIT 20150715 22991231 19000101 22991231 29 The time limit for filing has expired.

0557 MEPD LATE FILING 20150715 22991231 19000101 22991231 29 The time limit for filing has expired.

0568DISCHARGE DATE IS LESS THAN ADMIT DATE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid discharge information.

0570TOTAL DAYS LESS THAN COVERED DAYS 20150715 22991231 19000101 22991231 16



0571 SURGICAL PROCEDURE MISSING 20150715 22991231 19000101 22991231 16



0573TOTAL DAYS ON CLAIM CONFLICT WITH DATES SHOWN 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0574SERVICE DATES ARE NOT IN SAME MONTH 20150715 22991231 19000101 22991231 16



0575SURGERY DTE CANNOT BE OUTSIDE HDR DATES OF SERVICE 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID SURGERY DATE.

0577DETAIL SERVICE DATES ARE NOT IN SAME MONTH 20150715 22991231 19000101 22991231 16



0595MANUALLY SUSPEND FOR REVIEW 20150725 22991231 19000101 22991231 45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. M85

Subjected to review of physician evaluation and management services.

0596FILE SEPARATE CLAIMS FOR DIFFERENT YEARS 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N61 Rebill services on separate claims.

0602UNITS NOT EQUAL TO TEETH BILLED 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0606 INVALID OTHER PAYER DATE 20150715 22991231 19000101 22991231 16



0620TPL DEDUCTIBLE AMOUNT NOT NUMERIC 20150715 22991231 19000101 22991231 16



0621TPL COINSURANCE AMOUNT NOT NUMERIC 20150715 22991231 19000101 22991231 16



0622TPL COPAY AMOUNT NOT NUMERIC 20150715 22991231 19000101 22991231 16



0623 TPL PAID AMOUNT NOT NUMERIC 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0624TPL DETAIL PAYER DOES NOT HAVE MATCHING HDR PAYER 20150715 22991231 19000101 22991231 16


INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE.

0625TPL DETAIL PAYER HAS MULTIPLE MATCHING HDR PAYERS 20150715 22991231 19000101 22991231 16



0626TPL DETAIL PAYER ID HAS DUPLICATE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid payer identifier.

0627TPL HDR COINSURANCE <> SUM OF DTL COINSURANCE 20150715 22991231 19000101 22991231 16



0628TPL HDR DEDUCTIBLE NOT EQUAL SUM OF DTL DEDUCTIBLE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0629TPL HDR COPAY NOT EQUAL SUM OF DTL COPAY 20150715 22991231 19000101 22991231 16



0630TPL HDR PAID AMT NOT EQUAL SUM OF DTL PAID AMT 20150715 22991231 19000101 22991231 16



0631TPL - PATIENT RESPONSIBILITY IS ZERO FOR PAYER 20150715 22991231 19000101 22991231 16



0632TPL HDR PAYER HAS NO DETAIL PAYER INFORMATION 20150715 22991231 19000101 22991231 16



0633TPL HDR PAYER ID IS DUPLICATE OF ANOTHER HDR PAYER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0634TPL PAYER RESPONSIBILITY MISSING OR INVALID 20150715 22991231 19000101 22991231 16



0635TPL PAYER RESPONSIBILITY HIERARCHY IS DUPLICATE 20150715 22991231 19000101 22991231 16



0636TPL TOTAL PAID AMT NOT EQUAL SUM OF HDR PAID AMT 20150715 22991231 19000101 22991231 16



0637CLAIM WITH TPL AMOUNT MISSING TPL PAYER 20150715 22991231 19000101 22991231 16



0643 INVALID OTHER COVERAGE CODE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0644OTHER PAYER PAT RESP AMT IS INVALID 20150715 22991231 19000101 22991231 16



0645OTHER PAYER PAT RESP QUALIFIER IS INVALID 20150715 22991231 19000101 22991231 16



0646PT RESPONSIBILITY MUST BE GT ZERO 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid patient liability amount.

0647OTHER PAYER AMOUNT MUST BE GT ZERO 20150715 22991231 19000101 22991231 16



0666MO Systematic denial of recycled suspense. 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

0675ADJ - RECIPIENT ID NOT SUBMITTED 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0676ADJ - PROVIDER ID NOT SUBMITTED 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid designated provider number.

0677 ADJ - ORIGINAL ICN NOT FOUND 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid Payer Claim Control Number. Other terms exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (DCN).

0678ADJ - ORIGINAL ICN NOT SUBMITTED 20150715 22991231 19000101 22991231 16



0679ADJ - REQUEST RECIPIENT ID NOT FOUND 20150715 22991231 19000101 22991231 16



0680ADJ - REQUEST PROVIDER DOES NOT MATCH ORIGINAL 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid replacement claim information.


Checkwrite End Date



0681 ADJ - ORIGINAL ICN NOT FOUND 20150715 22991231 19000101 22991231 16



0682ADJ - ORIGINAL CLAIM HAS ALREADY BEEN ADJUSTED 20150715 22991231 19000101 22991231 97

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

0683ADJ - ORIG CLM ADJUSTMENT ALREADY IN PROGRESS 20150715 22991231 19000101 22991231 97


0684ADJ - REQUEST RECIPIENT DOES NOT MATCH ORIGINAL 20150715 22991231 19000101 22991231 16



0685ADJ - ORIGINAL CLAIM NOT IN A PAID STATUS 20150715 22991231 19000101 22991231 16


The original claim was denied. Resubmit a new claim, not a replacement claim.

0686ADJ - REPLACEMENT CLAIM NOT SAME CLAIM TYPE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0687

CANNOT ADJUST THIS CLAIM DUE TO PROVIDER CHANGES. VOID THIS CLAIM AND RESUBMIT 20150715 22991231 19000101 22991231 16



0688

CANNOT ADJUST THIS CLAIM DUE TO PHP TERMINATION. VOID THIS CLAIM AND RESUBMIT 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

0689ADJ - ORIGINAL CLAIM CANNOT BE ADJUSTED - NCCI 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

0690ADJUSTMENT RCO PROVIDER MISSING 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N63 Rebill services on separate claim lines.

0691RCO PROVIDER NOT PRESENT ON ORIGINAL CLAIM 20150715 22991231 19000101 22991231 16


0692ADJUSTMENT RCO PROVIDER DOES NOT MATCH MOTHER 20150715 22991231 19000101 22991231 16



Checkwrite End Date



0693FFS ADJUSTING ENCOUNTER OR ENCOUNTER ADJUSTING FFS 20150715 22991231 19000101 22991231 16


0800 DETAIL RATE NOT NUMERIC 20150715 22991231 19000101 22991231 16


0801DTL RATE * DTL UNITS NOT EQUAL DTL BILLED AMOUNT 20150715 22991231 19000101 22991231 16


0802MISSING OR INVALID PRESCRIBER ID QUALIFIER 20150715 22991231 19000101 22991231 16



0803DATED EXCEED SOBRA/QMB ELIGIBILITY 20150715 22991231 19000101 22991231 16



Checkwrite End Date



0804BILLING PROVIDER CANNOT BE PRESCRIBER 20150715 22991231 19000101 22991231 16



0805NONCOVERED CHARGE IS NOT NUMERIC 20150715 22991231 19000101 22991231 16


0806MEDICARE PAID AMOUNT MISSING OR INVALID 20150715 22991231 19000101 22991231 16


0807 INVALID TPL ADJUDICATION DATE 20150715 22991231 19000101 22991231 16



0808TPL ADJUDUCATION DATE CANNOT BE A FUTURE DATE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0809VERIFY LIFETIME RESERVE AND COINS DAYS TO COV DAYS 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid number of lifetime reserve days.

0810INVALID DEDUCTIBLE AMT - SKILLED NURSING FACILITY 20150715 22991231 19000101 22991231 16


0811HEADER FROM DATE OF SERVICE > ICN DATE 20150715 22991231 19000101 22991231 16



0812ADMIT DATE IS GREATER THAN ICN DATE 20150715 22991231 19000101 22991231 16



0813 MEDICARE PAID DATE > ICN DATE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0814DETAIL TO DATE OF SERVICE > ICN DATE 20150715 22991231 19000101 22991231 16



0815SURGICAL ICD REQUIRES OPERATING PHYSICIAN 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OPERATING PROVIDER PRIMARY IDENTIFIER.

0816COINSURANCE DAYS NOT NUMERIC 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid number of coinsurance days during the billing period.

0817 INVALID COINSURANCE DAYS 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid number of coinsurance days during the billing period.

0818LIFETIME RESERVE DAYS NOT NUMERIC 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0819LIFETIME RESERVE DAYS > MAX ALLOWED 20150715 22991231 19000101 22991231 16



0820FROM DOS AND TO DOS MAY NOT SPAN THE FISCAL YEAR 20150715 22991231 19000101 22991231 16


0821NON-COVERED DAYS MISSING OR NOT NUMERIC 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid noncovered days during the billing period.

0822SURGICAL REVENUE CODE REQUIRES ICD SURGERY CODE 20150715 22991231 19000101 22991231 199 Revenue code and Procedure code do not match. N657


0823RECIPIENT CHECK DIGIT IS MISSING OR INVALID 20150715 22991231 19000101 22991231 16



0824UNBORN RECIPIENT PENDING ELIGIBILITY VERIFICATION 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

0825MEDICARE ALLOWED AMOUNT MISSING OR INVALID 20150715 22991231 19000101 22991231 16



Checkwrite End Date



0826TYPE OF BILL INVALID FOR CLAIM TYPE 20150715 22991231 19000101 22991231 16


0829DAYS SUPPLY > 3 FOR EMERGENCY PHARMACY CLAIM 20150715 22991231 19000101 22991231 16



0830MEDICARE HDR ALLOW AMNT NOT EQUAL SUM OF DTL ALLOW 20150715 22991231 19000101 22991231 16


0831MEDICARE HDR PAID AMNT NOT EQUAL SUM OF DTL PAID 20150715 22991231 19000101 22991231 16


0832OTHER PAYER AMOUNT PAID QUALIFIER INVALID 20150715 22991231 19000101 22991231 16



Checkwrite End Date



0833CO-INSURANCE AMOUNT DOES NOT BALANCE 20150715 22991231 19000101 22991231 16


0835MEDICARE DATA NOT FOUND - FORMAT ERROR 20150715 22991231 19000101 22991231 16


0836

MEDICARE PAID, DEDUCTIBLE AMOUNTS INVALID - BOTH CANNOT BE ZERO **OR** MEDICAR 20150715 22991231 19000101 22991231 16


0837CLAIM DATES OVERLAP PLAN EFFECTIVE DATES 20150715 22991231 19000101 22991231 16



0838COPAY AMOUNT DOES NOT BALANCE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



0839REBILL SERVICES ON SEPARATE CLAIMS 20150715 22991231 19000101 22991231 16


0840ICD-10 CLAIM SPANS ICD-10 START DATE 20150715 22991231 19000101 22991231 16


0841ICD-9 CLAIM SPANS ICD-9 END DATE 20150715 22991231 19000101 22991231 16


0842 ES CLAIM REQUIRES DELIVERY 20150715 22991231 19000101 22991231 16



0843EMERG CLAIMS REQUIRE A CERTIFIED EMERGENCY 20150715 22991231 19000101 22991231 16


Claim information is inconsistent with pre-certified/authorized services.


Checkwrite End Date



0844HOSPICE CLAIM ONLY ONE LINE ALLOWED PER CLAIM ITEM. 20150715 22991231 19000101 22991231 16


0846FACILITY PROVIDER NOT SUBMITTED 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid provider number of the facility where the patient resides.

0924SYSTEM ERROR - ADJ - ORIGINAL CLAIM NOT FOUND 20150715 22991231 19000101 22991231 16



0927 DRG GROUP NOT FOUND 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N587 Policy benefits have been exhausted.

0928BIRTH WEIGHT CDE VALUE GROUP NOT FOUND 20150715 22991231 19000101 22991231 B5 Coverage/program guidelines were not met or were exceeded.

1000 NO PAY-TO PROVIDER RECORD 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY IDENTIFIER.

1001BILLING PROVIDER NOT ENROLLED FOR DATES OF SERVICE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid group practice information.


Checkwrite End Date



1002PERFORMING PROV NOT ELIGIBLE FOR DOS 20150715 22991231 19000101 22991231 B7

This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

1003PROVIDER INELIGIBLE ON DATE OF SERVICE 20150715 22991231 19000101 22991231 B7


1004BILLING PROVIDER NOT ENROLLED FOR DATES OF SERVICE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid group practice information.

1007RENDERING PROVIDER IDENTIFIER NOT ON FILE 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER.

1010PERFORMING PROVIDER NOT IN BILLING GROUP 20150715 22991231 19000101 22991231 B7


1017HOSPICE SNF RATE NOT ON FILE OR INVALID SNF SVC LOCATION 20150715 22991231 19000101 22991231 16


Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.

1018CLINIC RATE NOT ON FILE FOR HOSPITAL 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1019

MULTIPLE RATES FOR LEVEL OF CARE - RATE CHANGE OVERLAPS SERVICE DATES; SPLIT BI 20150715 22991231 19000101 22991231 239

Claim spans eligible and ineligible periods of coverage. Rebill separate claims. N144

The rate changed during the dates of service billed.

1020ATTENDING PHYSICIAN ID NOT ON FILE 20150715 22991231 19000101 22991231 16



1021FIRST OTHER (OPERATING) PROVIDER ID NOT ON FILE 20150715 22991231 19000101 22991231 16



1024BILLING PROVIDER NOT LISTED AS RECIPIENT LTC PROV 20150715 22991231 19000101 22991231 242

Services not provided by network/primary care providers. Notes: This code replaces deactivated code 38.

1026PRESCRIBING PHYSICIAN LICENSE NUMBER NOT ON FILE 20150715 22991231 19000101 22991231 16



1032PROVIDER TYPE - CLAIM INPUT CONFLICT 20150715 22991231 19000101 22991231 170

Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

1038DEA NOT ON FILE FOR PRESCRIBER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1039PRESCRIBER DEA NOT EFFECTIVE FOR DATE PRESCRIBED 20150715 22991231 19000101 22991231 16



1040PRESCRIBER DEA DOES NOT PERMIT DRUG SCHEDULE 20150715 22991231 19000101 22991231 16



1041PRESCRIBER PRACTICE TYPE NOT VALID FOR DRUG SCHED 20150715 22991231 19000101 22991231 16



1051RENDERING PROVIDER NOT ON PROVIDER DATABASE (HDR) 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OTHER PAYER RENDERING PROVIDER IDENTIFIER.

1054ORDERING PROVIDER NOT ON FILE 20150715 22991231 19000101 22991231 184

The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

1065 PROVIDER NAME MISMATCH 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER NAME.


Checkwrite End Date



1070ATTENDING PROVIDER ID NOT ON FILE - HDR 20150715 22991231 19000101 22991231 16



1071OPERATING PROVIDER ID NOT ON FILE - HDR 20150715 22991231 19000101 22991231 16



1072ATTENDING PROVIDER ID NOT ON FILE - DTL 20150715 22991231 19000101 22991231 16



1073OPERATING PROVIDER ID NOT ON FILE - DTL 20150715 22991231 19000101 22991231 16



1074PRESCRIBING PROVIDER NOT ON FILE 20150715 22991231 19000101 22991231 16



1079ORDERING PROV NOT ENROLLED SVC LOCATION 20150715 22991231 19000101 22991231 184



Checkwrite End Date



1081REFERRING PROV NOT ENROLLED SVC LOC HDR-PHYS-DNTL 20150715 22991231 19000101 22991231 16



1082REFERRING PROV NOT ENROLLED SVC LOC DTL-PHYS-DNTL 20150715 22991231 19000101 22991231 16



1083REFERRING PROV NOT ENROLLED AT SVC LOC - HDR - UB 20150715 22991231 19000101 22991231 16



1084ATTENDING PROV - NOT ENROLLED AT SVC LOC - HDR 20150715 22991231 19000101 22991231 16



1085OPERATING PROV - NOT ENROLLED AT SVC LOC - HDR 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1086REFERRING PROV - NOT ENROLLED AT SVC LOC - DTL-UB 20150715 22991231 19000101 22991231 16



1087ATTENDING PROV - NOT ENROLLED AT SVC LOC - DTL 20150715 22991231 19000101 22991231 16



1088OPERATING PROV - NOT ENROLLED AT SVC LOC - DTL 20150715 22991231 19000101 22991231 16



1089PRESCRIBING PROV - NOT ENROLLED AT SVC LOC 20150715 22991231 19000101 22991231 16



1091REFER PROV STATUS NOT VALID FOR DOS HDR-PHYS-DNTL 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1092REFER PROV STATUS NOT VALID FOR DOS DTL-PHYS-DNTL 20150715 22991231 19000101 22991231 16



1093REFERRING PROV STATUS NOT VALID FOR DOS - HDR - UB 20150715 22991231 19000101 22991231 16



1094ATTENDING PROV - STATUS NOT VALID FOR DOS - HDR 20150715 22991231 19000101 22991231 16



1095OPERATING PROV - STATUS NOT VALID FOR DOS - HDR 20150715 22991231 19000101 22991231 16



1096REFERRING PROV - STATUS NOT VALID FOR DOS - DTL-UB 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1097ATTENDING PROV - STATUS NOT VALID FOR DOS - DTL 20150715 22991231 19000101 22991231 16



1098OPERATING PROV - STATUS NOT VALID FOR DOS - DTL 20150715 22991231 19000101 22991231 16



1099PRESCRIBING PROV - STATUS NOT VALID FOR DOS 20150715 22991231 19000101 22991231 184


1100ORDERING PROV - STATUS NOT VALID FOR DOS 20150715 22991231 19000101 22991231 184


1200MATERNITY DISTRICT PROVIDER NOT ON FILE 20150715 22991231 19000101 22991231 16



1201MATERNITY DISTRICT PROVIDER MISSING OR SPACES 20150715 22991231 19000101 22991231 16



1202MATERNITY PROVIDER NOT A DISTRICT PROVIDER 20150715 22991231 19000101 22991231 8

The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N95

This provider type/provider specialty may not bill this service.


Checkwrite End Date



1203MATERNITY DISTRICT PROVIDER NOT ENROLLED 20150715 22991231 19000101 22991231 16



1204MATERNITY DISTRICT PROV STATUS NOT VALID FOR DOS 20150715 22991231 19000101 22991231 16



1205MATERNITY DISTRICT PROV NOT AN NPI 20150715 22991231 19000101 22991231 16



1206MATERNITY DISTRICT PAYER MISSING 20150715 22991231 19000101 22991231 16



1207MATERNITY DISTRICT PAYER - MORE THAN ONE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1208MATERNITY CLAIM FREQUENCY NOT 1 OR 8 20150715 22991231 19000101 22991231 16



1209MATERNITY CLAIM NOT AN ENCOUNTER 20150715 22991231 19000101 22991231 16



1210MATERNITY ENCOUNTER - INVALID CLAIM TYPE 20150715 22991231 19000101 22991231 16



1211MATERNITY ENCOUNTER - DUPLICATE CLAIM 20150715 22991231 19000101 22991231 18

Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO).

1212MATERNITY ENCOUNTER - VOID CLAIM 20150715 22991231 19000101 22991231 96

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA67 Correction to a prior claim.

1220

SUBMITTER DOES NOT BEGIN WITH TPIDRCO FOR ENCOUNTER CLAIMS 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1221

SUBMITTER BEGINS WITH TPIDRCO FOR NON-ENCOUNTER CLAIM 20150715 22991231 19000101 22991231 16



1225 BILLING PROVIDER TYPE IS RCO 20150715 22991231 19000101 22991231 16



1226 ENCOUNTER INDICATOR IS NOT Y 20150715 22991231 19000101 22991231 16



1227CLAIM IS FFS BUT SHOULD BE COVERED BY RCO 20150715 22991231 19000101 22991231 16



1228ENCOUNTER IS PHARMACY OR DENTAL CLAIM 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1229MATERNITY CARE ENCOUNTER SERVICE NOT COVERED 20150715 22991231 19000101 22991231 16



1230 ENCOUNTER PROVIDER MISSING 20150715 22991231 19000101 22991231 16



1231ENCOUNTER PROVIDER NOT ON FILE 20150715 22991231 19000101 22991231 16



1232ENCOUNTER PROVIDER NPI NOT SUBMITTED 20150715 22991231 19000101 22991231 16



1233ENC PROVIDER NOT ENROLLED AT SERVICE LOCATION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1234ENCOUNTER PROVIDER STATUS NOT VALID FOR DOS 20150715 22991231 19000101 22991231 16



1235ENCOUNTER PROVIDER MULTIPLE SERVICE LOCATIONS 20150715 22991231 19000101 22991231 16



1236RCO PROVIDER NOT A VALID RCO PROVIDER TYPE 20150715 22991231 19000101 22991231 16



1237FQHC FFS RCO CLAIM MISSING RCO PAYER 20150715 22991231 19000101 22991231 16



1238FQHC FFS RCO CLAIM RCO PAID AMT ZERO 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1239FQHC SUBMITTED RCO DOES NOT MATCH RECIPIENT RCO 20150715 22991231 19000101 22991231 16



1240ENCOUNTER CLAIM RECIPIENT IS NOT IN AN RCO 20150715 22991231 19000101 22991231 16



1241ENCOUNTER CLAIM DATES OF SERVICE NOT ALL IN RCO 20150715 22991231 19000101 22991231 16



1242ENCOUNTER RECIPIENT CHANGES RCO DURING DOS 20150715 22991231 19000101 22991231 16



1243ENCOUNTER CLAIM RCO DOES NOT MATCH RECIPIENT RCO 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1250NO ENCOUNTER PAYER SUBMITTED 20150715 22991231 19000101 22991231 16



1251MORE THAN ONE ENCOUNTER PAYER SUBMITTED 20150715 22991231 19000101 22991231 16



1252 ENCOUNTER TCN MISSING 20150715 22991231 19000101 22991231 16



1253ENCOUNTER ADJUDICATION DATE INVALID 20150715 22991231 19000101 22991231 16



1254ENCOUNTER ADJUDICATION DATE CANNOT BE IN FUTURE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1255ENCOUNTER MISSING DETAIL PAYER INFORMATION 20150715 22991231 19000101 22991231 16



1256ENCOUNTER COPAY NOT NUMERIC 20150715 22991231 19000101 22991231 16



1257ENCOUNTER PAID AMOUNT NOT NUMERIC 20150715 22991231 19000101 22991231 16



1258ENCOUNTER SUM OF DTL COPAY NOT EQUAL HDR COPAY 20150715 22991231 19000101 22991231 16



1259ENCOUNTER SUM OF DTL PAID NOT EQUAL HDR PAID 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1260ENCOUNTER COINSURANCE SUBMITTED 20150715 22991231 19000101 22991231 16



1261ENCOUNTER DEDUCTIBLE SUBMITTED 20150715 22991231 19000101 22991231 16



1262ENCOUNTER PAID AMOUNT SUBMITTED 20150715 22991231 19000101 22991231 16



1280 RCO DENIED CLAIM 20150715 22991231 19000101 22991231 16



1281 RCO DENIED CLAIM - TPL 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1282RCO DENIED CLAIM - TIMELY FILING 20150715 22991231 19000101 22991231 16



1283RCO DENIED CLAIM - NOT AN RCO COVERED SERVICE 20150715 22991231 19000101 22991231 16



1284RCO DENIED CLAIM - MISSING AUTHORIZATION OR REFERRAL 20150715 22991231 19000101 22991231 16



1803BILLING PROVIDER MUST BE GROUP PROVIDER NUMBER 20150715 22991231 19000101 22991231 16



1804VERIFY PERFORMING PROVIDER NOT GROUP PROVIDER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1805BILLING PROVIDER SPECIALTY NOT FOUND FOR CLAIM DOS 20150715 22991231 19000101 22991231 16



1806

EPSDT REFERRED SVCS RESTRICTED TO RECIPIENTS UNDER 20150715 22991231 19000101 22991231 6

The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

1807CROSSOVER ONLY PROVIDER CANNOT BILL CLAIM TYPE 20150715 22991231 19000101 22991231 16



1808REFERRING PROVIDER IS MISSING OR NOT ON FILE 20150715 22991231 19000101 22991231 16



1809REFERRING PROVIDER-NO SCREENING SPECIALTY FOR DOS 20150715 22991231 19000101 22991231 16



1810PERFORMING PROVIDER SPECIALTY NOT FOUND FOR DOS 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1812RECIPIENT / ADMIT AGE GREATER THAN 21 20150715 22991231 19000101 22991231 6


1813PROVIDER SUSPENDED FOR OUTSTANDING CREDIT BALANCE 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID PAY-TO PROVIDER PRIMARY IDENTIFIER.

1814BILLING PROVIDER NOT VALID FOR DATES OF SERVICE 20150715 22991231 19000101 22991231 16



1815PERF PROV ENROLL STATUS NOT VALID FOR DOS 20150715 22991231 19000101 22991231 16



1816MATERNITY CARE MUST BE PERFORMED BY DISTRICT PROV 20150715 22991231 19000101 22991231 242


1817MATERNITY CARE PROV CAN ONLY BILL MATERNITY SVCS 20150715 22991231 19000101 22991231 8

The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N95

This provider type/provider specialty may not bill this service.

1818 WAIVER PROVIDER MISMATCH 20150715 22991231 19000101 22991231 242Services not provided by network/primary care providers. Notes: This code replaces deactivated code 38.

1819INVALID POS FOR FQHC PROVIDER 20150715 22991231 19000101 22991231 5

The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. M77



Checkwrite End Date



1820PATIENT FIRST CLAIM REQUIRES A REFERRAL 20150715 22991231 19000101 22991231 16



1821MEDICAL LOCKIN - RECIPIENT LOCKED IN TO OTHER PROVIDER 20150715 22991231 19000101 22991231 242


1822MEDICAL LOCKIN - LOCKIN DATES OVERLAP CLAIM DATES 20150715 22991231 19000101 22991231 16



1823WAIVER ASSIGNMENT DATES OVERLAP CLAIM DATES 20150715 22991231 19000101 22991231 16



1824LTC ASSIGNMENT DATES OVERLAP CLAIM DATES 20150715 22991231 19000101 22991231 16



1825COBA DENIAL - DO NOT CROSSOVER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1826

SERVICE FOR MATERNITY WAIVER/CARE RECIPIENT MUST BE BILLED WITH GLOBAL SERVICE 20150715 22991231 19000101 22991231 B7


1827NON-MEPD CLAIM FOR MEPD RECIPIENT 20150715 22991231 19000101 22991231 16



1828BILLING PROVIDER NOT VALID FOR DATES OF SERVICE 20150715 22991231 19000101 22991231 16



1829PERF PROV ENROLL STATUS NOT VALID FOR DOS 20150715 22991231 19000101 22991231 16



1830PROCEDURE REQUIRES BOTH ORDERING AND REF PROVIDER 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID ORDERING PROVIDER PRIMARY IDENTIFIER.

1831PROCEDURE REQUIRE EITHER ORDERING OR REF PROVIDER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1832PROCEDURE REQUIRES REFERRING PROVIDER 20150715 22991231 19000101 22991231 16



1833PROCEDURE REQUIRES ORDERING PROVIDER 20150715 22991231 19000101 22991231 16



1834SUBMITTER ID/EVVM PROCEDURE CONFLICT 20150715 22991231 19000101 22991231 16



1835PROVIDER UNDER REVIEW - BILLING 20150715 22991231 19000101 22991231 251

The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or remittance Advice Remark Code that is not an ALERT). N28 Consent form requirements not fulfilled.

1836PROVIDER UNDER REVIEW - PERFORMING 20150715 22991231 19000101 22991231 251


1900TAXONOMY IS INVALID BILLING PROVIDER 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID BILLING PROVIDER TAXONOMY.


Checkwrite End Date



1901TAXONOMY IS INVALID PREFORMING PROVIDER 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY.

1906TAXONOMY IS NOT VALID FOR BILLING PROVIDER 20150715 22991231 19000101 22991231 16



1907TAXONOMY IS NOT VALID FOR PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16



1912TAXONOMY IS MISSING: BILLING PROVIDER 20150715 22991231 19000101 22991231 16



1913TAXONOMY IS MISSING: PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1919TAXONOMY IS INVALID: DTL PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16



1921TAXONOMY IS MISSING: DTL PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16



1925TAXONOMY IS NOT VALID FOR DTL PERFORMING PROV 20150715 22991231 19000101 22991231 16



1927

BILLING PROVIDER - NPI MISSING OR INVALID - AN NPI NUMBER IS REQUIRED AND WAS N 20150715 22991231 19000101 22991231 16



1928NPI REQUIRED HEALTHCARE=Y PREMING PROV 20150715 22991231 19000101 22991231 16



1929NPI REQUIRED HEALTHCARE=Y REFERRING PROV 20150715 22991231 19000101 22991231 206 National Provider Identifier - missing N265



Checkwrite End Date



1931NPI REQUIRED HEALTHCARE=Y RENDERING PROV 20150715 22991231 19000101 22991231 16



1934

DTL NPI REQUIRED HEALTHCARE=Y PERFORMING PROV 20150715 22991231 19000101 22991231 16



1935DTL NPI REQUIRED HEALTHCARE=Y REFERRING PROV 20150715 22991231 19000101 22991231 206 National Provider Identifier - missing N265


1936INVALID BILLING PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16



1937INVALID PREFORMING PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16



1938INVALID REFERRING PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1939INVALID FACILITY PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OTHER PAYER SERVICE FACILITY PROVIDER IDENTIFIER.

1940INVALID RENDERING PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16



1941INVALID OTHER PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OTHER PROVIDER PRIMARY IDENTIFIER.

1942INVALID DTL OTHER PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16



1943INVALID DTL PREFORMING PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1944INVALID DTL REFERRING PROVIDER SPECIFIED 20150715 22991231 19000101 22991231 16



1945MULTIPLE SERVICE LOCATIONS FOR BILLING PROVIDER 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER SECONDARY IDENTIFIER.

1946MULTIPLE SERVICE LOCATIONS FOR PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID RENDERING PROVIDER SECONDARY IDENTIFIER.

1949MULTIPLE SERVICE LOCATIONS FOR RENDERING PROVIDER 20150715 22991231 19000101 22991231 16



1952MULTIPLE SERVICE LOCS FOR DTL PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1960NPI REQUIRED: ATTENDING PROVIDER (HEALTHCARE) 20150715 22991231 19000101 22991231 16



1961NPI REQUIRED: OPERATING PROVIDER (HEALTHCARE) 20150715 22991231 19000101 22991231 16



1962NPI REQUIRED: REFERRING PROVIDER (HEALTHCARE) 20150715 22991231 19000101 22991231 16



1963ATTENDING PROVIDER - NPI REQUIRED - HDR 20150715 22991231 19000101 22991231 16



1964OPERATING PROVIDER- NPI REQUIRED - HDR 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1965ATTENDING PROVIDER- NPI REQUIRED - DTL 20150715 22991231 19000101 22991231 16



1966OPERATING PROVIDER- NPI REQUIRED - DTL 20150715 22991231 19000101 22991231 16



1968NPI REQUIRED: ORDERING PROVIDER (HEALTHCARE) 20150715 22991231 19000101 22991231 16



1969INVALID DTL ORDERING PROVIDER OVERRIDE SPECIFIED 20150715 22991231 19000101 22991231 16



1970INVALID ATTENDING PROVIDER OVERRIDE SPECIFIED 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1971INVALID DTL ATTENDING PROVIDER OVERRIDE SPECIFIED 20150715 22991231 19000101 22991231 16



1972INVALID OTHER PROVIDER 1 OVERRIDE SPECIFIED 20150715 22991231 19000101 22991231 16



1973INVALID DTL OTHER PROVIDER 1 OVERRIDE SPECIFIED 20150715 22991231 19000101 22991231 16



1974TAXONOMY IS INVALID: DTL PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16



1975TAXONOMY IS INVALID: DTL REFERRING PROVIDER 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID REFERRING PROVIDER TAXONOMY.


Checkwrite End Date



1976TAXONOMY IS INVALID: DTL OTHER PROVIDER 2 20150715 22991231 19000101 22991231 16



1977TAXONOMY IS NOT VALID FOR DTL OTHER PROVIDER 2 20150715 22991231 19000101 22991231 16



1978TAXONOMY IS NOT VALID FOR DTL PERFORMING PROV 20150715 22991231 19000101 22991231 16



1979TAXONOMY IS NOT VALID FOR DTL REFERRING PROVIDER 20150715 22991231 19000101 22991231 16



1980TAXONOMY IS NOT VALID FOR BILLING PROVIDER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1981TAXONOMY IS NOT VALID FOR PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16



1982TAXONOMY IS NOT VALID FOR REFERRING PROVIDER 20150715 22991231 19000101 22991231 16



1983TAXONOMY IS NOT VALID FOR FACILITY PROVIDER 20150715 22991231 19000101 22991231 16



1984TAXONOMY IS NOT VALID FOR OTHER PROVIDER 2 20150715 22991231 19000101 22991231 16



1985TAXONOMY IS INVALID: BILLING PROVIDER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



1986TAXONOMY IS INVALID: PERFORMING PROVIDER 20150715 22991231 19000101 22991231 16



1987TAXONOMY IS INVALID: REFERRING PROVIDER 20150715 22991231 19000101 22991231 16



1988TAXONOMY IS INVALID: FACILITY PROVIDER 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID SERVICE FACILITY SECONDARY IDENTIFIER.

1989TAXONOMY IS INVALID: OTHER PROVIDER 2 20150715 22991231 19000101 22991231 16



1995MMIS FACILITY PROVIDER ID NOT ENROLLED 20150715 22991231 19000101 22991231 16



1996

THE RENDERING PROVIDER IS NOT ENROLLED IN THE MEDICAID PROGRAM. 20150715 22991231 19000101 22991231 185

The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.


Checkwrite End Date



1999

PROVIDER ID IS INVALID, IS NOT ON FILE OR NAME/NUMBER DISAGREE. 20150715 22991231 19000101 22991231 16



2001RECIPIENT IS NOT ON ELIGIBILITY FILE 20150715 22991231 19000101 22991231 16



2002RECIPIENT NOT ELIGIBLE FOR HEADER DATE OF SERVICE 20150715 22991231 19000101 22991231 26 Expenses incurred prior to coverage. N30 Patient ineligible for this service.

2003ITEMIZED SERVICE DATE NOT IN ELIGIBILITY SPAN 20150715 22991231 19000101 22991231 26 Expenses incurred prior to coverage. N30 Patient ineligible for this service.

2009RECIPIENT INELIGIBLE ON DATE OF SERVICE 20150715 22991231 19000101 22991231 26 Expenses incurred prior to coverage. N30 Patient ineligible for this service.

2042PATIENT LIABILITY SEGMENT OVERLAP 20150715 22991231 19000101 22991231 16



2045ITEM NOT PAYABLE IN LONG TERM CARE FACILITY 20150715 22991231 19000101 22991231 96


2046RECIPIENT PATIENT STATUS INVALID FOR CLAIM 20150715 22991231 19000101 22991231 16




Checkwrite End Date



2047ADMIT REASON/SOURCE OF ADMISSION MISSING/INVALID 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid admission source.

2048RECIPIENT DISCHARGE RSN MISSING/INVALID(SUSPEND) 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid discharge information.

2050ADMIT DATE MUST EQUAL HDR FIRST SVC DATE 20150715 22991231 19000101 22991231 16



2056RECIPIENT ELIGIBILITY - CHIP OVERLAP 20150715 22991231 19000101 22991231 16



2057RECIPIENT PARTIALLY ELIGIBILE - HEADER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



2077RECIPIENT IS NOT ELIGIBLE ALL DATES OF SERVICES 20150715 22991231 19000101 22991231 16



2500RECIPIENT COVERED BY MEDICARE A (NO ATTACHMENT) 20150715 22991231 19000101 22991231 109

Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

2501RECIPIENT COVERED BY MEDICARE A (WITH ATTACHMENT 20150715 22991231 19000101 22991231 109


2502RECIPIENT COVERED BY MEDICARE B (NO ATTACHMENT) 20150715 22991231 19000101 22991231 109


2503

RECIPIENT COVERED BY MEDICARE B (WITH ATTACHMENT) 20150715 22991231 19000101 22991231 109


2504FILE SHOWS OTHER INSURANCE, SUBMIT TO OTHER CARRIER 20150715 22991231 19000101 22991231 22

This care may be covered by another payer per coordination of benefits. N4

Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.

2505RECIPIENT COVERED BY PRIVATE INSURANC(W/ATTACHMNT) 20150715 22991231 19000101 22991231 22



2507THIS PATIENT HAS TWO COVERAGE TYPES 20150715 22991231 19000101 22991231 22



2508RECIPIENT COVERED BY PRIVATE INSURANCE (PHARMACY) 20150715 22991231 19000101 22991231 22



2550MEDICAID HAS NO LIABILITY BILL MEDICARE ADV. PLAN 20150715 22991231 19000101 22991231 109


2603RECIPIENT LOCK-IN TO SPECIFIC PRESCRIBING PROVIDER 20150715 22991231 19000101 22991231 206 National Provider Identifier - missing N31


2800

STERILIZATION DENIED BECAUSE DOCUMENTATION DOES NOT MEET HHS/MEDICAID REQUIREME 20150715 22991231 19000101 22991231 251


2801

HYSTERECTOMY DENIED BECAUSE DOCUMENTATION DOES NOT MEET HHS/MEDICAID REQUIREMEN 20150715 22991231 19000101 22991231 251



Checkwrite End Date



2802

ABORTION DENIED BECAUSE DOCUMENTATION DOES NOT MEET HHS/MEDICAID REQUIREMENTS. 20150715 22991231 19000101 22991231 251


2804DETAILS COVERED BY MORE THAN ONE PLAN CODE 20150715 22991231 19000101 22991231 16


2805 DOS PRIOR TO DOB 20150715 22991231 19000101 22991231 14 The date of birth follows the date of service.

2806PREGNANCY INDICATOR IS INVALID FOR RECIPIENT SEX 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA39 Missing/incomplete/invalid gender.

2807COBA-NO MEDICAID ID FOR MEDICARE ID 20150715 22991231 19000101 22991231 16



2808 COBA - MEDICARE ID NOT ON FILE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



2809OFFICE VISIT REQUIRES GESTATIONAL AGE DIAGNOSIS 20150715 22991231 19000101 22991231 16



2810DETAIL HAS MORE THAN ONE GESTATIONAL DIAGNOSIS CODE 19000101 22991231 19000101 22991231 16



2811MORE THAN ONE GESTATIONAL DIAGNOSIS CODE SUBMITTED 19000101 22991231 19000101 22991231 16



3000UNITS EXCEED AUTHORIZED UNITS ON PA MASTER FILE 20150715 22991231 19000101 22991231 16


Claim information is inconsistent with pre-certified/authorized services.

3001 PA NOT FOUND ON DATABASE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid treatment authorization code.


Checkwrite End Date



3002 NDC REQUIRES PA 20150715 22991231 19000101 22991231 16



3003PROCEDURE REQUIRES PRIOR AUTHORIZATION 20150715 22991231 19000101 22991231 16



3006PRIOR AUTH UNITS/AMOUNTS USED 20150715 22991231 19000101 22991231 16


3019 PA CUTBACK PERFORMED 20150725 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. N123

This is a split service and represents a portion of the units from the originally submitted service.

3100CLAIM AND PA PRESCRIBING PROV DON'T MATCH 20150715 22991231 19000101 22991231 16



3101ONLINE PA DENIED BY HID, NDC REQUIRES PA 20150715 22991231 19000101 22991231 16



3102ONLINE PA PROCESS TIMEOUT OR INTERFACE PROBLEM 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.


Checkwrite End Date



3103ONLINE PA PROCESS RESPONSE FROM HID HAD ERRORS 20150715 22991231 19000101 22991231 16



3104PA REQUIRED FOR CERTAIN TRANSPORTATION SERVICES 20150715 22991231 19000101 22991231 16



3105DAW 1 - BRAND WITH GENERIC EQUIVALENT REQUIRES OVERRIDE 20150715 22991231 19000101 22991231 16



3300NEONATAL REVENUE - DIAGNOSIS CODE MISMATCH 20150715 22991231 19000101 22991231 16



3301BILL EMERGENCY PROCEDURE/REVENUE TOGETHER 20150715 22991231 19000101 22991231 16




Checkwrite End Date



3302PROCEDURE AND REVENUE CODE COMBINATION NOT VALID 20150715 22991231 19000101 22991231 16



3303MEDICARE PAID AMOUNT EQUAL 100% 20150715 22991231 19000101 22991231 16



3304NON-COVERED SVC FOR RECIPIENT < 6 MONTHS OLD 20150715 22991231 19000101 22991231 6


3305 NO BASE VALUE FOR ANESTHESIA 20150715 22991231 19000101 22991231 16



3306HEADER PAID AMOUNT EXCEEDS SPECIFIED DOLLAR AMOUNT 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

3307FQHC/PBRHC FFS/ENCOUNTER PROCEDURE CONFLICT 20150715 22991231 19000101 22991231 16




Checkwrite End Date



3308PROCEDURE CODE/MODIFIER NOT ON RATE FILE 20150715 22991231 19000101 22991231 16



3309PROCEDURE CODE - TYPE OF BILL RESTRICTION 20150715 22991231 19000101 22991231 16


3311REFILL NUMBER EXCEEDS MAXIMUM ALLOWED 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid name, strength, or dosage of the drug furnished.

3312DAYS SUPPLY IS GREATER THAN MAXIMUM DAYS SUPPLY 20150715 22991231 19000101 22991231 16



3313NDC DRUG, PRODUCT IS NOT PREFERRED 20150715 22991231 19000101 22991231 16




Checkwrite End Date



3314PHARMACY ONLY - OTC DRUG NOT COVERED FOR LTC RECIP 20150715 22991231 19000101 22991231 16



3315 NURSERY DAYS EXCEED LIMIT 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N362


3316PHARMACY ONLY - NDC IS NOT PAYABLE BY ALABAMA MEDICAID 20150715 22991231 19000101 22991231 16



3317CLAIM QUANTITY EXCEEDS NDC MAX UNITS 20150715 22991231 19000101 22991231 16



3320SERVICE INCLUDED IN FACILITY FEE 20150715 22991231 19000101 22991231 97

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N20

Service not payable with other service rendered on the same date.

3321

NO PRICING SEGMENT ON FILE - CONTACT MYERS AND STAUFFER AT 1-800-591-1183. 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

3322DAW CODE NOT ALLOWED WITH NDC SUMITTED 20150715 22991231 19000101 22991231 16



3323PROCEDURE RESTRICTION - MODIFIER REQUIRED 20150715 22991231 19000101 22991231 182 Procedure modifier was invalid on the date of service.


Checkwrite End Date



3324PROCEDURE RESTRICTION - NOT ALLOWED 20150715 22991231 19000101 22991231 4

The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

3325QUANTITY MUST BE DIVISIBLE BY PACKAGE SIZE 20150715 22991231 19000101 22991231 16



3326PHARMACY MAINTENANCE SUPPLY REQUIRED FOR DRUG 20150715 22991231 19000101 22991231 16



3327NDC HAS INVALID THERAPEUTIC CLASS VALUE 20150715 22991231 19000101 22991231 16



3328RCO HDR PAID CLAIM PROCEDURE ALREADY PRESENT 20150715 22991231 19000101 22991231 16



3351

PRIMARY DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16




Checkwrite End Date



3352

SECOND DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3353

THIRD DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3354

FOURTH DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3355

FIFTH DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3356

SIXTH DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16




Checkwrite End Date



3357

SEVENTH DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3358

EIGHTH DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3359

NINTH DIAGNOSIS REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3360

DIAGNOSIS 10-42 REQUIRES PRESENT ON ADMISSION INDICATOR 20150715 22991231 19000101 22991231 16



3375TCM SVCS NOT ALLOWED FOR SAIL / E AND D WAIVERS 20160501 22991231 19000101 22991231 97



3376FQHC ENCOUNTER EXCLUSION DETAIL 20150715 22991231 19000101 22991231 16




Checkwrite End Date



3599 MANUAL PRICING REQUIRED 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

3800SERVICE COVERAGE HAS NOT BEEN DETERMINED 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

3998BPA-RR-REV - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



3999BPA-RR-PROC - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4001BPA-RP-DIAG - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 12

The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N657


4002 BPA-RP-NDC - NO COVERAGE 20150715 22991231 19000101 22991231 16



4004 NDC IS NOT ON FILE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4013PROCEDURE CODE IS NO LONGER VALID 20150715 22991231 19000101 22991231 16



4014 NO PRICING SEGMENT IS ON FILE. 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

4016BPA-RP-DIAG - PERF PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 12

The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N657


4021 BPA-RP-PROC - NO COVERAGE 20150715 22991231 19000101 22991231 16



4023BPA-RP-NDC - GENDER RESTRICTION 20150715 22991231 19000101 22991231 16


4025 BPA-RP-NDC - AGE RESTRICTION 20150715 22991231 19000101 22991231 6


4027DIAGNOSIS CODE NOT COVERED FOR DATE OF SERVICE 20150715 22991231 19000101 22991231 146 Diagnosis was invalid for the date(s) of service reported.

4028BPA-RP-DIAG - GENDER RESTRICTION 20150715 22991231 19000101 22991231 10

The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.


Checkwrite End Date



4029BPA-RP-DIAG - PLACE OF SERVICE RESTRICTION 20150715 22991231 19000101 22991231 16



4030 BPA-RP-DIAG - AGE RESTRICTION 20150715 22991231 19000101 22991231 9

The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

4031BPA-PC-DIAG - GENDER RESTRICTION 20150715 22991231 19000101 22991231 10

The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N657


4032PROCEDURE CODE IS MISSING/NOT ON FILE 20150715 22991231 19000101 22991231 16



4034 BPA-RP-PROC - AGE RESTRICTION 20150715 22991231 19000101 22991231 6


4035BPA-RP-PROC - GENDER RESTRICTION 20150715 22991231 19000101 22991231 7

The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

4036BPA-RP-PROC - PLACE OF SERVICE RESTRICTION 20150715 22991231 19000101 22991231 5

The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

4038PATIENT REASON FOR VISIT DIAGNOSIS NOT ON FILE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4040PRIMARY DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4041SECONDARY DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4042THIRD DIAGNOSIS CODE NOT ON FILE OR INACTIVE 20150715 22991231 19000101 22991231 16



4043FOURTH DIAGNOSIS CODE NOT ON FILE OR INACTIVE 20150715 22991231 19000101 22991231 16



4044BPA-RR-DIAG - NO RULE FOR ASSOC AGE 20150715 22991231 19000101 22991231 9


4045BPA-RR - NO RULE FOR BENEFIT PLAN 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

4046DATE OF SERVICE BEFORE PROCEDURE IS PAYABLE 20150715 22991231 19000101 22991231 96

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N56

Procedure code billed is not correct/valid for the services billed or the date of service billed.


Checkwrite End Date



4047FIFTH DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4048SIXTH DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4049SEVENTH DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4050EIGHTH DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4051NINTH DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4052ADMITTING DIAGNOSIS CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4053PRINCIPAL PROCEDURE CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4054FIRST OTHER PROCEDURE CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4055SECOND OTHER PROCEDURE CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4056THIRD OTHER PROCEDURE CODE NOT ON FILE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4057FOURTH OTHER PROCEDURE CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4058FIFTH OTHER PROCEDURE CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4059 REVENUE CODE NOT ON FILE 20150715 22991231 19000101 22991231 16



4061BPA-RR - NO RULE FOR CLAIM TYPE 20150715 22991231 19000101 22991231 16



4062BPA-RR - NO RULE FOR COND CODE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4064BPA-RP-ICD - GENDER RESTRICTION 20150715 22991231 19000101 22991231 16


4068BPA-RR - NO RULE CURR BILL PROV CONTRACT 20150715 22991231 19000101 22991231 B7


4070BPA-RR-PROC - MODIFIER RESTRICTION 20150715 22991231 19000101 22991231 4


4071BPA-RR-PROC - TOOTH NUMBER RESTRICTION 20150715 22991231 19000101 22991231 16



4072BPA-RR-DRG - NO RULE FOR ADMIT OR HDR DIAGNOSIS 20150715 22991231 19000101 22991231 16



4073BPA-RP-DIAG - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4075BPA-RP-ICD - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16



4076BPA-RP-NDC - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16



4077 NON-COVERED REVENUE CODE 20150715 22991231 19000101 22991231 16



4093BPA-RP-DIAG - DIAG ROLE RESTRICTION 20150715 22991231 19000101 22991231 16



4094BPA-PC-REV - PROV COUNTY RESTRICTION 20150715 22991231 19000101 22991231 B7


4104BPA-RP-PROC - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4106BPA-RP-REV - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16



4109BPA-PC-DIAG - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16



4112BPA-PC-ICD - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16



4117BPA-PC-NDC - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16



4118BPA-PC-PROC - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4120ORAL CAVITY DESIGNATION CODE INVALID 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid oral cavity designation code.

4128ICD PROCEDURE 7-24 NOT ON FILE 20150715 22991231 19000101 22991231 16



4136BPA-RP-ICD - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4138BPA-RP-NDC - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4140BPA-RP-PROC - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4141BPA-RP-PROC - PERF PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4142BPA-RP-REV - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4143BPA-RP-REV - PERF PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4144BPA-PC-DIAG - PERF PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4149BPA-PC-PROC - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4150BPA-PC-PROC - PERF PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4151BPA-PC-REV - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4152BPA-PC-REV - PERF PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4154BPA-PC-REV - FAMILY PLANNING IND RESTRICTION 20150715 22991231 19000101 22991231 16



4155BPA-RR-PROC - PLACE OF SERVICE RESTRICTION 20150715 22991231 19000101 22991231 16



4157BPA-PC-DIAG - CURR PROV CONTRACT RESTRICTION 20150715 22991231 19000101 22991231 B7



Checkwrite End Date



4159BPA-PC-ICD - CURR PROV CONTRACT RESTRICTION 20150715 22991231 19000101 22991231 B7


4160BPA-PC-NDC - CURR PROV CONTRACT RESTRICTION 20150715 22991231 19000101 22991231 B7


4161BPA-PC-PROC - CURR PROV CONTRACT RESTRICTION 20150715 22991231 19000101 22991231 B7


4162BPA-PC-REV - CURR PROV CONTRACT RESTRICTION 20150715 22991231 19000101 22991231 B7


4164 INACTIVE DRUG 20150715 22991231 19000101 22991231 16



4166BPA-RR-NDC - NO RULE FOR BENEFIT PLAN 20150715 22991231 19000101 22991231 16



4167BPA-RR-REV - NO RULE FOR BENEFIT PLAN 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4177BPA-PC-ICD - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4194BPA-RP-PROC - OTHER DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4200 CLAIM PRICED AT ZERO 20150725 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. N524

Based on policy this payment constitutes payment in full.

4207CLIA NUMBER NOT ON FILE FOR DATES OF SERVICE 20150715 22991231 19000101 22991231 16


Missing/incomplete/invalid CLIA certification number.

4208CLIA NUMBER NOT EFFECTIVE FOR ENTIRE SVC PERIOD 20150715 22991231 19000101 22991231 16



4210BPA-RR-REV - ANY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4211INVALID TOOTH NUMBER FOR THIS PROCEDURE 20150715 22991231 19000101 22991231 16



4212BILLING OUT OF CLIA CERTIFICATE TYPE 20150715 22991231 19000101 22991231 16



4215BPA-RP-PROC - TOOTH NUMBER RESTRICTION 20150715 22991231 19000101 22991231 16



4219BPA-RR-REV - NO RULE FOR TYPE OF BILL 20150715 22991231 19000101 22991231 16


4224BPA-RP-PROC - QUANTITY RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4225INVALID INPATIENT REVENUE CODE 20150715 22991231 19000101 22991231 16



4226DIAGNOSIS MUST BE BILLED AT THE HIGHEST SUBDIVISION 20150715 22991231 19000101 22991231 16


YOU ARE REQUIRED TO CODE TO THE HIGHEST LEVEL OF SPECIFICITY.

4227 BPA-RP-REV - NO COVERAGE 20150715 22991231 19000101 22991231 16



4231BPA-PC-NDC - MAX UNIT RESTRICTION 20150715 22991231 19000101 22991231 16



4240THIS PROCEDURE MUST BE BILLED SEPARATELY EACH DATE 20150715 22991231 19000101 22991231 16


Dates of service span multiple rate periods. Resubmit separate claims.


Checkwrite End Date



4244 BPA-RP-DIAG - NO COVERAGE 20150715 22991231 19000101 22991231 16



4245FOURTH MODIFIER INVALID FOR DATE OF SERVICE 20150715 22991231 19000101 22991231 182 Procedure modifier was invalid on the date of service.

4250BPA-RR - NO RULE FOR PRIMARY PT/PS BILL/PERF 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

4251DECIMAL UNITS NOT BILLABLE FOR PROCEDURE. 20150715 22991231 19000101 22991231 16



4252DIAGNOSIS CODE 10-24 NOT ON FILE 20150715 22991231 19000101 22991231 16



4254 BPA-RP-REV - AGE RESTRICTION 20150715 22991231 19000101 22991231 6


4256BPA-RP-PROC - MODIFIER RESTRICTION 20150715 22991231 19000101 22991231 4


4257BPA-PC-PROC - MODIFIER RESTRICTION 20150715 22991231 19000101 22991231 4



Checkwrite End Date



4260 NDC REQUIRED FOR PROCEDURE 20150715 22991231 19000101 22991231 16



4261INVALID UNIT OF MEASURE VALUE 20150715 22991231 19000101 22991231 16



4262NDC QUANTITY UNITS IS NOT NUMERIC 20150715 22991231 19000101 22991231 16



4263 NDC QUANTITY UNITS IS ZERO 20150715 22991231 19000101 22991231 16



4264 NDC NOT ON THE DRUG FILE 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4265

INVALID HCPCS/NDC COMBINATION FOR PRIMARY NDC 20150715 22991231 19000101 22991231 16



4266NDC NOT COVERED - PRIMARY NDC NOT ACTIVE ON DOS 20150715 22991231 19000101 22991231 16



4267NDC NOT COVERED - SECONDARY NDC NOT ACTIVE ON DOS 20150715 22991231 19000101 22991231 16



4268NDC NOT COVERED - NDC NOT REBATABLE ON DOS 20150715 22991231 19000101 22991231 16



4269NDC NOT COVERED - SECOND NDC NOT REBATABLE ON DOS 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4270NDC NOT COVERED - NDC RATED LESS THAN EFFECTIVE 20150715 22991231 19000101 22991231 16



4271DUPLICATE NDC FOR CLAIM DETAIL 20150715 22991231 19000101 22991231 16



4272NDC NOT COVERED - OBSOLETE OR TERMINATED ON DOS 20150715 22991231 19000101 22991231 16



4273INVALID NDC QUALIFIER CODE, MUST EQUAL N4 20150715 22991231 19000101 22991231 16



4274INVALID PRESCRIPTION QUALIFIER CODE, MUST EQUAL XZ 20150715 22991231 19000101 22991231 175 Prescription is incomplete. N668 Incomplete/invalid prescription.

4275DRUG UNIT PRICE IS NOT NUMERIC 20150715 22991231 19000101 22991231 175 Prescription is incomplete. N668 Incomplete/invalid prescription.

4276 DRUG UNIT PRICE IS ZERO 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4277 PROCEDURE REQUIRES NDC 20150715 22991231 19000101 22991231 16



4278NDC NOT COVERED - NDC NOT EFFECTIVE ON THE DOS 20150715 22991231 19000101 22991231 16



4279NDC NOT COVERED - NDC INACTIVE ON THE DOS 20150715 22991231 19000101 22991231 16



4280NDC NOT COVERED - NDC IN REJECT REGARDLESS ON DOS 20150715 22991231 19000101 22991231 16



4281NDC NOT COVERED - REPACKAGED NDC 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4282

PROCEDURE MUST BE SUBMITTED ON PAPER WITH APPROPRIATE NDC, DRUG DESCRIPTION, AN 20150715 22991231 19000101 22991231 16



4283MANUAL PRICE NON-CLASSIFIED PROCEDURE 20150715 22991231 19000101 22991231 189

'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.

4310BPA-PC-PROC - ADMIT DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4311BPA-PC-PROC - PRIMARY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4312BPA-PC-PROC - PRIMARY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4313BPA-PC-PROC - SECONDARY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4314BPA-RP-DIAG - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4315BPA-PC-PROC - ANY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4316BPA-PC -ANY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4317BPA-PC-ICD - ADMIT DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4318BPA-PC-ICD - PRIMARY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4319BPA-PC-ICD - ANY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4320BPA-PC-REV - ADMIT DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4321BPA-PC-REV - PRIMARY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4322BPA-PC-REV - ANY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4362BPA-PC-DIAG - TYPE OF BILL RESTRICTION 20150715 22991231 19000101 22991231 16



Checkwrite End Date



4364BPA-PC-ICD - TYPE OF BILL RESTRICTION 20150715 22991231 19000101 22991231 16


4371BPA-RP-PROC - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4372BPA-PC-PROC - SECONDARY HDR DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4373BPA-RP-NDC - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4374BPA-RP-REV - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4376BPA-RP-ICD - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4400BPA-RP-PROC - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4401BPA-PC-PROC - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4402BPA-RR-PROC - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4403BPA-RP-ICD - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4404BPA-PC-ICD - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4405BPA-RR-ICD - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4406BPA-RP-REV - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4407BPA-PC-REV - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4408BPA-RR-REV - ADMITTING DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4409BPA-RP-PROC - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4410BPA-PC-PROC - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4411BPA-RR-PROC - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4412BPA-RP-ICD - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4413BPA-PC-ICD - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4414BPA-RR-ICD - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4415BPA-RP-REV - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4416BPA-PC-REV - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4417BPA-RR-REV - PRIMARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4418BPA-RP-PROC - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4419BPA-PC-PROC - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4420BPA-RR-PROC - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4421BPA-RP-ICD - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4422BPA-PC-ICD - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4423BPA-RR-ICD - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4424BPA-RP-REV - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4425BPA-PC-REV - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4426BPA-RR-REV - SECONDARY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4427BPA-RP-PROC - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4428BPA-PC-PROC - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4429BPA-RR-PROC - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4430BPA-RP-ICD - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4431BPA-PC-ICD - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4432BPA-RR-ICD - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4433BPA-RP-REV - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4434BPA-PC-REV - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4435BPA-RR-REV - OTHER HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4436BPA-RP-PROC - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4437BPA-PC-PROC - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4438BPA-RR-PROC - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4439BPA-RP-ICD - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4440BPA-PC-ICD - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4441BPA-RR-ICD - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4442BPA-RP-REV - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4443BPA-PC-REV - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4444BPA-RR-REV - EMERGENCY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4445BPA-RR-PROC - ANY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4446BPA-RP-ICD - ANY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4447BPA-PC-ICD - ANY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4448BPA-RR-ICD - ANY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4449BPA-RP-REV - ANY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4450BPA-PC-REV - ANY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4451BPA-RR-REV - ANY HDR DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4479BPA-RP-PROC - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4480BPA-PC-PROC - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4481BPA-RR-PROC - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4482BPA-RP-ICD - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4483BPA-PC-ICD - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4484BPA-RR-ICD - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4485BPA-RP-REV - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4486BPA-PC-REV - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4487BPA-RR-REV - OTHER ANY DIAGNOSIS GROUP RESTRICTION 20150715 22991231 19000101 22991231 16



4500 BPA-RR-NDC - ALGI RESTRICTION 20150715 22991231 19000101 22991231 16



4501BPA-RR-NDC - NO RULE FOR DISP AS WRITTEN IND 20150715 22991231 19000101 22991231 16



4502BPA-RP-PROC - EPSDT REFERRAL RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4503BPA-PC-PROC - EPSDT REFERRAL RESTRICTION 20150715 22991231 19000101 22991231 16



4504 BPA-RP-NDC - ALGI RESTRICTION 20150715 22991231 19000101 22991231 16



4505BPA-RR-PROC - NO RULE FOR URBAN/RURAL IND 20150715 22991231 19000101 22991231 16



4506BPA-PC-DIAG - PERF PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4508BPA-PC-PROC - PERF PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4509BPA-PC-REV - PERF PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4511BPA-RP-DIAG - PERF PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4514BPA-RP-PROC - PERF PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4515BPA-RP-REV - PERF PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4516BPA-PC-DIAG - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4517BPA-PC-NDC - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4518BPA-PC-ICD - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4519BPA-PC-PROC - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4520BPA-PC-REV - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4521BPA-RP-DIAG - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4522BPA-RP-NDC - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4523BPA-RP-ICD - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4524BPA-RP-PROC - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4525BPA-RP-REV - BILL PROV ALL PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4526BPA-PC-PROC - PROV COUNTY RESTRICTION 20150715 22991231 19000101 22991231 B7


4529BPA-RP-REV - PROV COUNTY RESTRICTION 20150715 22991231 19000101 22991231 B7



Checkwrite End Date



4530BPA-RR-PROC - SECONDARY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4532BPA-RR-ICD - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4533BPA-RP-REV - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4535BPA-RP-ICD - EMERGENCY DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4536BPA-RP-PROC - EMERGENCY DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4538BPA-RP-REV - EMERGENCY DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4539BPA-PC-PROC - EMERGENCY DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4540BPA-PC-PROC - MIN UNIT RESTRICTION 20150715 22991231 19000101 22991231 16



4560BPA-RP-ICD - SECONDARY HDR DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4561BPA-RP-REV - SECONDARY HDR DIAG RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4562BPA-RP-REV - GENDER RESTRICTION 20150715 22991231 19000101 22991231 16


4563BPA-RR - NO RULE CURR PERF PROV CONTRACT 20150715 22991231 19000101 22991231 B7


4564BPA-RR-PROC - HDR SECONDARY DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4565BPA-RR-ICD - HDR SECONDARY DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4566BPA-RR-REV - HDR SECONDARY DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4580BPA-RP-PROC - DIAGNOSIS RESTRICTION - GROUP 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4581BPA-PC-PROC - DIAGNOSIS RESTRICTION - GROUP 20150715 22991231 19000101 22991231 16



4711 BPA-PC-DIAG - AGE RESTRICTION 20150715 22991231 19000101 22991231 9


4713 BPA-PC-NDC - AGE RESTRICTION 20150715 22991231 19000101 22991231 6


4714 BPA-PC-PROC - AGE RESTRICTION 20150715 22991231 19000101 22991231 6


4715 BPA-PC-REV - AGE RESTRICTION 20150715 22991231 19000101 22991231 6


4716 BPA-PC-ICD - AGE RESTRICTION 20150715 22991231 19000101 22991231 16



4723BPA-RP-ICD - PRIMARY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4724BPA-RP-ICD - ANY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4726BPA-RP-ICD - ADMIT DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4731BPA-RP-PROC - ANY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4732BPA-RP-REV - ADMIT DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4733BPA-RP-REV - ANY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4736BPA-RP-REV - PRIMARY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4741BPA-RP-PROC - ADMIT DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4742BPA-RP-PROC - PRIMARY HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4743BPA-RP-PROC - SECONDARY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4744BPA-RP-PROC - SECONDARY HDR DIAG RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4745BPA-RP-PROC - DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4746BPA-RP-PROC - PRIMARY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4747BPA-PC-ICD - HDR SECONDARY DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4748BPA-PC-REV - SECONDARY HDR DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4751BPA-PC-REV - TYPE OF BILL RESTRICTION 20150715 22991231 19000101 22991231 16



Checkwrite End Date



4755BPA-PC-PROC - CURRENT BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4756BPA-PC-DIAG - CURRENT BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4757BPA-PC-REV - CURRENT BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4762BPA-PC-ICD - PLACE OF SERVICE RESTRICTION 20150715 22991231 19000101 22991231 16



4765 BPA-RP-ICD - NO COVERAGE 20150715 22991231 19000101 22991231 16



4766 BPA-RP-ICD - AGE RESTRICTION 20150715 22991231 19000101 22991231 6



Checkwrite End Date



4767BPA-RP-ICD - PLACE OF SERVICE RESTRICTION 20150715 22991231 19000101 22991231 16



4775BPA-PC-NDC - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4776BPA-PC-DIAG - BILL PROV PRIMARY PT/PS RESTRICTION 20150715 22991231 19000101 22991231 16



4801 BPA-PC-PROC - NO CONTRACT 20150715 22991231 19000101 22991231 16



4802 BPA-PC-DIAG - NO CONTRACT 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4803 BPA-PC-NDC - NO CONTRACT 20150715 22991231 19000101 22991231 16



4804 BPA-PC-REV - NO CONTRACT 20150715 22991231 19000101 22991231 16



4806 BPA-PC-ICD - NO CONTRACT 20150715 22991231 19000101 22991231 16



4821BPA-PC-PROC - PLACE OF SERVICE RESTRICTION 20150715 22991231 19000101 22991231 16



4822BPA-PC-DIAG - PLACE OF SERVICE RESTRICTION 20150715 22991231 19000101 22991231 16



4831 BPA-RR - NO REIMB RULE 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.


Checkwrite End Date



4835BPA-PC-PROC - OTHER DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16



4871BPA-PC-PROC - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4872BPA-PC-DIAG - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4873BPA-PC-NDC - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4874BPA-PC-REV - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4876BPA-PC-ICD - CLAIM TYPE RESTRICTION 20150715 22991231 19000101 22991231 16



4900BPA-RP-DIAG - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4901BPA-RP-DIAG - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4902BPA-RP-DIAG - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID OCCURRENCE CODE(S).

4905BPA-RP-ICD - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4906BPA-RP-PROC - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4910BPA-PC-DIAG - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4911BPA-PC-DIAG - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4912BPA-PC-DIAG - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4913BPA-XX-DIAG - DIAG ROLE RESTRICTION -PC and RR 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4923BPA-PC-ICD - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4927BPA-RP-DIAG - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4928BPA-RP-PROC - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4929BPA-RP-REV - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4933BPA-PC-PROC - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4937BPA-PC-DIAG - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4938BPA-PC-PROC - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4939BPA-PC-REV - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4940BPA-RP-ICD - BENE PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4941BPA-RP-ICD - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4942BPA-RP-ICD - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4943BPA-PC-REV - OTHER HDR DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4944BPA-PC-ICD - GENDER RESTRICTION 20150715 22991231 19000101 22991231 16


4947BPA-RR-NDC - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4948BPA-RR-PROC - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4949BPA-RR-REV - ASSIGNMENT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4950BPA-PC-ICD - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4951BPA-PC-ICD - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4952BPA-PC-ICD - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4960BPA-RP-NDC - BENE PLAN RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4961BPA-RP-PROC - PROV COUNTY RESTRICTION 20150715 22991231 19000101 22991231 16



4962BPA-PC-NDC - GENDER RESTRICTION 20150715 22991231 19000101 22991231 16


4963BPA-PC-PROC - GENDER RESTRICTION 20150715 22991231 19000101 22991231 16


4964BPA-PC-REV - GENDER RESTRICTION 20150715 22991231 19000101 22991231 16


4965BPA-PC-NDC - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4966 BPA-RR - DIAGNOSIS RESTRICTION 20150715 22991231 19000101 22991231 16



4970BPA-RP-REV - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4971BPA-RP-REV - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4972BPA-RP-REV - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4973BPA-RR-PROC - ANY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4975BPA-PC-REV - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4976BPA-PC-REV - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4977BPA-PC-REV - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4980BPA-RP-PROC - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4981BPA-RP-PROC - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4982BPA-RP-PROC - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4990BPA-PC-PROC - BENEFIT PLAN RESTRICTION 20150715 22991231 19000101 22991231 16



4991BPA-PC-PROC - CONDITION CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4992BPA-PC-PROC - OCCURRENCE CODE RESTRICTION 20150715 22991231 19000101 22991231 16



4993BPA-RR-PROC - PRIMARY DTL DIAG RESTRICTION 20150715 22991231 19000101 22991231 16




Checkwrite End Date



4994BPA-RP-NDC - SPECIFIC THERA CLASS RESTRICTION 20150715 22991231 19000101 22991231 16



4999

RECIPIENT IS PART D ELIGIBLE - CLAIM NOT COVERED. IF A RECIPIENT HAS MEDICAREP 20150715 22991231 19000101 22991231 96


5000

OUR RECORDS SHOW THIS SERVICE HAS ALREADY BEEN PAID FOR THE DATE OF SERVICE BIL 20150715 22991231 19000101 22991231 18


5001



5002



5003 ENCOUNTER EXACT DUPLICATE 20150715 22991231 19000101 22991231 50

These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N227

INCOMPLETE/INVALID CERTIFICATE OF MEDICAL NECESSITY.

5005 DENTAL DUPLICATE EXACT 20150715 22991231 19000101 22991231 18


5006



5010

OUR RECORDS SHOW THIS SERVICE FOR THE DATE(S) OF SERVICE BILLED IS A DUPLICATE. 20150715 22991231 19000101 22991231 18


5011



5012




Checkwrite End Date



5013



5014



5015



5016



5017



5018



5019 ENCOUNTER EXACT DUPLICATE 20150715 22991231 19000101 22991231 50


INCOMPLETE/INVALID CERTIFICATE OF MEDICAL NECESSITY.

5020SUSPECT DUPLICATE OF ANOTHER PHARMACY CLAIM. 20150715 22991231 19000101 22991231 18


5021EXACT DUPLICATE OF ANOTHER PHARMACY CLAIM. 20150715 22991231 19000101 22991231 18


5022DUPLICATE RX NUMBER FOR SAME DATE OF SERVICE. 20150715 22991231 19000101 22991231 97



5200

ADMINISTRATION FEE MAY NOT BE BILLED ON THE SAME DAY AS AN OFFICE VISIT AND/OR 20150715 22991231 19000101 22991231 97



5201

ADMINISTRATION FEE MAY NOT BE BILLED ON THE SAME DAY AS AN OFFICE VISIT AND/OR 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5202

CHEMOTHERAPY ADMINISTRATION FEE MAY NOT BE BILLED ON THE SAME DAY AS THIS PROCE 20150715 22991231 19000101 22991231 97



5203

CHEMOTHERAPY ADMINISTRATION FEE MAY NOT BE BILLED ON THES AME DAY AS THIS PROCE 20150715 22991231 19000101 22991231 97



5204

VENIPUNCTURE AND LAB CODES ARE NOT ALLOWED ON THE SAME DAY. 20150715 22991231 19000101 22991231 97



5205

VENIPUNCTURE AND LAB CODES ARE NOT ALLOWED ON THE SAME DAY. 20150715 22991231 19000101 22991231 97



5206THIS SERVICE IS INCLUDED IN THE FACILITY FEE 20150715 22991231 19000101 22991231 97



5207THIS SERVICE IS INCLUDED IN THE FACILITY FEE 20150715 22991231 19000101 22991231 97



5208

ADMINISTRATION FEE MAY NOT BE BILLED ON THE SAME DAY AS THIS PROCEDURE CODE. 20150715 22991231 19000101 22991231 97



5209

ADMINISTRATION FEE MAY NOT BE BILLED ON THE SAME DAY AS THIS PROCEDURE CODE. 20150715 22991231 19000101 22991231 97



5210

OUTPATIENT CHEMOTHERAPY AND EMERGENCY DEPARTMENT SERVICE CODES MAY NOT BE BILLE 20150715 22991231 19000101 22991231 97



5211

OUTPATIENT CHEMOTHERAPY AND EMERGENCY DEPARTMENT SERVICE CODES MAY NOT BE BILLE 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5213

PROCEDURE CODE CANNOT BE BILLED ON THE SAME DAY WITH PROCEDURE CODES Z5181-Z518 20150715 22991231 19000101 22991231 97



5214PROCEDURE CODE NOT ALLOWED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5216COMBINATION VACCINES/SINGLE COMPONENT CONTRA 20150715 22991231 19000101 22991231 97



5217

SINGLE COMPONENT/COMBINATION VACCINES CONTRA 20150715 22991231 19000101 22991231 97



5218SUPPLY CODE CANNOT BE BILLED WITH LAB OR OFFICE VISIT 20150715 22991231 19000101 22991231 97



5219

SUPPLY CODE HAS BEEN PAID IN HISTORY, CANNOT BILL A LAB OR OFFICE VISIT 20150715 22991231 19000101 22991231 97



5230

SUBSEQUENT PROCEDURE INCLUDED IN PRIMARY ANESTHESIA CHARGE 20150715 22991231 19000101 22991231 97



5231

SUBSEQUENT PROCEDURE INCLUDED IN PRIMARY ANESTHESIA CHARGE 20150715 22991231 19000101 22991231 97



5232

DAILY MANAGEMENT OF AN EPIDURAL OR SUBARACHNOID CATHETER MAYNOT BE BILLED ON TH 20150715 22991231 19000101 22991231 97



5233

DAILY MANAGEMENT OF AN EPIDURAL OR SUBARACHNOID CATHETER MAYNOT BE BILLED ON TH 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5234

ADDITIONAL PAIN CONTROL PROCEDURES PAID AT 50% OF MEDICAID ALLOWED. 20150725 22991231 19000101 22991231 45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. N524


5235

ADDITIONAL PAIN CONTROL PROCEDURES PAID AT 50% OF MEDICAID ALLOWED. 20150725 22991231 19000101 22991231 45



5236QUALIFYING PROCEDURE LIMIT HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 97



5237

ANESTHESIA NOT PAYABLE WITH OTHER ANESTHESIA ON SAME DATE OF SERVICE 20150715 22991231 19000101 22991231 97


TIME FRAME REQUIREMENTS BETWEEN THIS SERVICE/PROCEDURE/SUPPLY AND A RELATED SERVICE/PROCEDURE/SUPPLY HAVE NOT BEEN MET.

5238

PHYSICIAN VISIT CODES/PRIMARY ANESTHESIA CODES MAY NOT BE BILLED WITHIN 3 DAYS 20150715 22991231 19000101 22991231 97



5239

PHYSICIAN VISIT CODES/PRIMARY ANESTHESIA CODES MAY NOT BE BILLED WITHIN 3 DAYS 20150715 22991231 19000101 22991231 97



5240

THIS PROCEDURE IS PART OF ANOTHER PROCEDURE PERFORMED ON THE SAME DAY. 20150715 22991231 19000101 22991231 97



5241

THIS PROCEDURE IS PART OF ANOTHER PROCEDURE PERFORMED ON THE SAME DAY. 20150715 22991231 19000101 22991231 97



5242

OUR RECORDS SHOW THIS NON-EMERGENCY TRANSPORT SERVICE HAS ALREADY BEEN PAID FOR 20150715 22991231 19000101 22991231 18


5260

BATTERIES MAY NOT BE PURCAHSED WITHIN 60 (SIXTY) DAYS OF PURCHASE OF HEARING AI 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5261

BATTERIES MAY NOT BE PURCAHSED WITHIN 60 (SIXTY) DAYS OF PURCHASE OF HEARING AI 20150715 22991231 19000101 22991231 97



5262

PROCEDURE CODES 92553, 92556 AND 92557 CANNOT BE BILLED ON THE SAME DAY BY THE 20150715 22991231 19000101 22991231 97



5270

CLINIC CODES Z5145-Z5149 CANNOT BE BILLED ON THE SAME DAY WITH SAME UNIQUE NUMB 20150715 22991231 19000101 22991231 97



5271

CLINIC CODES AND E&M CODES CANNOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5280PROCEDURE CODE NOT COVERED WHEN BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97
















Checkwrite End Date



5285DME HUMIDIFIER OR CPAP/CPAP CONTRA 20150715 22991231 19000101 22991231 97



5286DME CPAP OR HUMIDIFIER/CPAP CONTRA 20150715 22991231 19000101 22991231 97



5287DME CATHETER CONTRA FOR A4221 20150715 22991231 19000101 22991231 97


5288DME HUMIDIFIER OR BIPAP/BIPAP CONTRA 20150715 22991231 19000101 22991231 97



5289DME BIPAP OR HUMIDIFIER/BIPAP CONTRA 20150715 22991231 19000101 22991231 97



5291REPLACEMENT/REPAIR INCLUDED IN WARRANTY 20150715 22991231 19000101 22991231 97


5300PULP THERAPY COMBINATION NOT ALLOWED IN THIS CASE 20150715 22991231 19000101 22991231 97













Checkwrite End Date


































Checkwrite End Date



5314PULP THERAPY COMBINATION NOT ALLOWED 20150715 22991231 19000101 22991231 97































Checkwrite End Date



5324

WHEN PROPHYLAXIS AND FLUORIDE ARE PERFORMED ON THE SAME DAY,THE COMBINED CODE M 20150715 22991231 19000101 22991231 97



5325

WHEN PROPHYLAXIS AND FLUORIDE ARE PERFORMED ON THE SAME DAY,THE COMBINED CODE M 20150715 22991231 19000101 22991231 97



5326CORE BUILDUP NOT COVERED WITH OTHER RESTORATION 20150715 22991231 19000101 22991231 97



5327CORE BUILDUP NOT COVERED WITH OTHER RESTORATION 20150715 22991231 19000101 22991231 97



5328

TWO RESTORATIONS NOT COVERED FOR THE SAME TOOTH NUMBER. 20150715 22991231 19000101 22991231 97

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. M86

SERVICE DENIED BECAUSE PAYMENT ALREADY MADE FOR SAME/SIMILAR PROCEDURE WITHIN SET TIME FRAME.

5329

TWO RESTORATIONS NOT COVERED FOR THE SAME TOOTH NUMBER. 20150715 22991231 19000101 22991231 97



5330

TWO RESTORATIONS NOT COVERED FOR THE SAME TOOTH NUMBER SAME DATE OF SERVICE. 20150715 22991231 19000101 22991231 97



5331

TWO RESTORATIONS NOT COVERED FOR THE SAME TOOTH NUMBER SAME DATE OF SERVICE. 20150715 22991231 19000101 22991231 97



5332

THIS X-RAY PROCEDURE MAY NOT BE BILLED WITHIN 30 (THIRTY) DAYS OF A ROOT CANAL 20150715 22991231 19000101 22991231 97



5333

THIS X-RAY PROCEDURE MAY NOT BE BILLED WITHIN 30 (THIRTY) DAYS OF A ROOT CANAL 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5334

PALLIATIVE (EMERGENCY)TREATMENT MAY NOT BE BILLED WITH DEFINITIVE TREATMENT OR 20150715 22991231 19000101 22991231 97



5335

PALLIATIVE (EMERGENCY)TREATMENT MAY NOT BE BILLED WITH DEFINITIVE TREATMENT OR 20150715 22991231 19000101 22991231 97



5336

DENTAL RECEMENT OF CROWNS NOT ALLOWED WITHIN 180 DAYS OF CROWN. 20150715 22991231 19000101 22991231 97



5338ORAL EXAM EVALUATIONS ARE LIMITED TO ONE PER DAY. 20150715 22991231 19000101 22991231 119

Benefit maximum for this time period or occurrence has been reached.

5340ORAL EVALUATION < 3 YRS (D0145) CONTRA 20150715 22991231 19000101 22991231 119

Benefit maximum for this time period or occurrence has been reached. M86


5342DENTAL FLOURIDE SAME DOS CONTRA 20150715 22991231 19000101 22991231 119



5350NO EXTRACTION CODE IN HISTORY IN 180 TIME FRAME. 20150715 22991231 19000101 22991231 97


This service/report cannot be billed separately.

5351PULP CAP NOT ALLOWED FOR THIS TOOTH/DATE OF SERVICE. 20150715 22991231 19000101 22991231 97



5352CLAIMS HISTORY SHOWS TOOTH HAS BEEN EXTRACTED. 20150715 22991231 19000101 22991231 97


5353CLAIMS HISTORY SHOWS TOOTH HAS BEEN EXTRACTED. 20150715 22991231 19000101 22991231 97



Checkwrite End Date



5354

TEMPORARY FILLING NOT PAYABLE ON SAME DATE OF SERVICE AS DEFINITIVE FILLING 20150715 22991231 19000101 22991231 97



5355

TEMPORARY FILLING NOT PAYABLE ON SAME DATE OF SERVICE AS DEFINITIVE FILLING 20150715 22991231 19000101 22991231 97



5400

PROCEDURE CANNOT BE BILLED ON THE SAME DAY BY THE PROVIDER 20150715 22991231 19000101 22991231 97



5401

PROCEDURE CANNOT BE BILLED ON THE SAME DAY BY THE PROVIDER 20150715 22991231 19000101 22991231 97



5402

SCREENING PROVIDER MAY NOT BILL FOR SCREENING EXAM AND INCLUSIVE MEDICAL SERVIC 20150715 22991231 19000101 22991231 97



5403

SCREENING PROVIDER MAY NOT BILL FOR SCREENING EXAM AND INCLUSIVE MEDICAL SERVIC 20150715 22991231 19000101 22991231 97



5404

EPSDT VISIT HAS BEEN PAID FOR THIS RECIPIENT FOR THE SAME DATE OF SERVICE. 20150715 22991231 19000101 22991231 97



5410

MORE THAN ONE CONTACT LENS FITTING CANNOT BE BILLED FOR THE SAME DATE OF SERVIC 20150715 22991231 19000101 22991231 97



5411

MORE THAN ONE CONTACT LENS FITTING CANNOT BE BILLED FOR THE SAME DATE OF SERVIC 20150715 22991231 19000101 22991231 97



5412

PROCEDURE CODE V2020 AND V2025 CANNOT BE BILLED ON THE SAME DAY OF SERVICE. 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5413

PROCEDURE CODE V2020 AND V2025 CANNOT BE BILLED ON THE SAME DAY OF SERVICE. 20150715 22991231 19000101 22991231 97



5414

EPSDT VISION SCREEN AND EXTERNAL OCULAR PHOTOGRAPHY NOT COVERED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5415

EPSDT VISION SCREEN AND EXTERNAL OCULAR PHOTOGRAPHY NOT COVERED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5416

VISUAL FIELDS/TONOMETRY IS COVERED IN THE COMPLETE EYE EXAM 20150715 22991231 19000101 22991231 97



5417

VISUAL FIELDS/TONOMETRY IS COVERED IN THE COMPLETE EYE EXAM 20150715 22991231 19000101 22991231 97



5430

AN INITIAL VISIT WILL NOT BE PAID ON SAME DATE OF SERVICE ASAN ANNUAL, PERIODIC 20150715 22991231 19000101 22991231 97



5431

AN INITIAL VISIT WILL NOT BE PAID ON SAME DATE OF SERVICE ASAN ANNUAL, PERIODIC 20150715 22991231 19000101 22991231 97



5432

PRENATAL VISIT NOT COVERED FOR THE SAME DATE OF SERVICE OF FAMILY PLANNING. 20150715 22991231 19000101 22991231 97



5433

PRENATAL VISIT NOT COVERED FOR THE SAME DATE OF SERVICE OF FAMILY PLANNING. 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5434

PROCEDURE LIMITED TO ONE SERVICE DURING 60 (SIXTY) DAY POSTPARTUM PERIOD. 20150715 22991231 19000101 22991231 97



5436

SALPINGECTOMY WILL NOT BE PAID ON THE SAME DAY AS A TUBAL LIGATION 20150715 22991231 19000101 22991231 97



5437

SALPINGECTOMY WILL NOT BE PAID ON THE SAME DAY AS A TUBAL LIGATION 20150715 22991231 19000101 22991231 97



5438

COMPREHENSIVE EPSDT SCREENING AND FP VISIT MAY NOT BE BILLED ON THE SAME DAY. 20150715 22991231 19000101 22991231 97



5439

COMPREHENSIVE EPSDT SCREENING AND FP VISIT MAY NOT BE BILLEDON THE SAME DAY. 20150715 22991231 19000101 22991231 97



5440FAMILY PLANNING VISIT NOT PAYABLE AFTER STERILIZATION 20150715 22991231 19000101 22991231 97


5441FAMILY PLANNING VISIT NOT PAYABLE AFTER STERILIZATION 20150715 22991231 19000101 22991231 97


5442FP-LEVONORGESTREL-CONTRA (J7302-5 YR) 20150715 22991231 19000101 22991231 119



5443FP-LEVONORGESTREL-CONTRA (Q0090-3 YR) 20150715 22991231 19000101 22991231 119



5451

HOME HEALTH PROVIDERS CANNOT BILL INPATIENT AND OUTPATIENT SERVICES ON THE SAME 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5455 HOSPICE ONE PER DAY CONTRA 20150715 22991231 19000101 22991231 97



5456HOSPICE ROUTINE CARE DOD REQUIRED FOR RN/SW ADD-ON 20150715 22991231 19000101 22991231 97



5457

HOSPICE CONTINUOUS CARE VS RN/SW ADD-ON PAYMENT CONTRA 20150715 22991231 19000101 22991231 97



5460

PROCEDURE CODE IS PART OF THE OUTPATIENT SURGICAL PROCEDURE REIMBURSEMENT. 20150715 22991231 19000101 22991231 97



5461




5462

THIS SERVICE IS INCLUDED IN THE FACILITY FEE (REVENUE CODE 450). 20150715 22991231 19000101 22991231 97



5464




5465




5470

THIS PROCEDURE IS PART OF ANOTHER PROCEDURE PERFORMED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5471





Checkwrite End Date



5472

CHEMISTRY PROFILE AND CHEMICAL PANEL CANNOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5473

CHEMISTRY PROFILE AND CHEMICAL PANEL CANNOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5474

COMPONENTS OF A CBC MAY NOT BE BILLED ON THE SAME DAY AS A COMPLETE CBC 20150715 22991231 19000101 22991231 97



5475




5476




5477




5478

COMPONENTS OF A URINALYSIS MAY NOT BE BILLED ON THE SAME DAY AS URINALYSIS 20150715 22991231 19000101 22991231 97



5479

COMPONENTS OF A URINALYSIS MAY NOT BE BILLED ON THE SAME DAY AS URINALYSIS 20150715 22991231 19000101 22991231 97



5480




5481





Checkwrite End Date



5482




5483




5484

LAB SERVICES MUST BE BILLED WITH COMBINATION CODE. SEE CPT. 20150715 22991231 19000101 22991231 97



5486

CHEMISTRY PROFILES MUST BE BILLED USING ONE MULTICHANNEL TEST CODE 20150715 22991231 19000101 22991231 97



5488




5490LAB-CHLAMYDIA/GONORRHEA CONTRA 20150715 22991231 19000101 22991231 97
















Checkwrite End Date



5504

POSTPARTUM VISIT WILL NOT BE PAID ON THE SAME DAY AS PRENATAL VISIT 20150715 22991231 19000101 22991231 97



5505

POSTPARTUM VISIT WILL NOT BE PAID ON THE SAME DAY AS PRENATAL VISIT 20150715 22991231 19000101 22991231 97



5506SERVICE NOT PAYABLE WITH OTHER SERVICE ON SAME DAY 20150715 22991231 19000101 22991231 97



5507SERVICE NOT PAYABLE WITH OTHER SERVICE ON SAME DAY 20150715 22991231 19000101 22991231 97



5508

SECONDARY SURGICAL PROCEDURE WITHIN THE SAME INCISION PAID AT 50% OF MEDICAID A 20151204 22991231 19000101 22991231 45


Please refer to your provider manual for additional program and provider information.

5509

SECONDARY SURGICAL PROCEDURE WITHIN THE SAME INCISION PAID AT 50% OF MEDICAID A 20151204 22991231 19000101 22991231 45



5510

PROCEDURE CODE IS LIMITED TO ONE PER RECIPIENT WITHIN SIXTY DAYS OF DELIVERY 20150715 22991231 19000101 22991231 119



5511

PROCEDURE CODE IS LIMITED TO ONE PER RECIPIENT WITHIN 60 DAYS OF DELIVERY. 20150715 22991231 19000101 22991231 119



5512

PRENATAL VISIT NOT BE COVERED ON THE SAME DAY AS POSTPARTUM VISIT. 20150715 22991231 19000101 22991231 97



5513

PRENATAL VISIT NOT BE COVERED ON THE SAME DAY AS POSTPARTUM VISIT. 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5514

THIS PROCEDURE CANNOT BE BILLED IN ADDITION TO THE DELIVERY CODE BILLED 20150715 22991231 19000101 22991231 97



5515

THIS PROCEDURE CANNOT BE BILLED IN ADDITION TO THE DELIVERY CODE BILLED 20150715 22991231 19000101 22991231 97



5516

ANTEPARTUM, POSTPARTUM CARE/VAGINAL DELIVERY MAY NOT BE BILLED WITH GLOBAL OB C 20150715 22991231 19000101 22991231 97



5517

ANTEPARTUM, POSTPARTUM CARE/VAGINAL DELIVERY MAY NOT BE BILLED WITH GLOBAL OB C 20150715 22991231 19000101 22991231 97



5518

LOCAL ANESTHESIA PROCEDURES ARE COVERED IN THE TOTAL OB COST AND MAY NOT BE BIL 20150715 22991231 19000101 22991231 97



5519

LOCAL ANESTHESIA PROCEDURES ARE COVERED IN THE TOTAL OB COST AND MAY NOT BE BIL 20150715 22991231 19000101 22991231 97



5520REGIONAL ANESTHESIA PAYMENT IS 50% OF LEVEL III PRICE 20151204 22991231 19000101 22991231 45



5521REGIONAL ANESTHESIA PAYMENT IS 50% OF LEVEL III PRICE 20151204 22991231 19000101 22991231 45



5522

ROUTINE PRENATAL LAB, OFFICE/HOSPITAL VISITS MAY NOT BE BILLED WITH GLOBAL OB P 20150715 22991231 19000101 22991231 97



5523

ROUTINE PRENATAL LAB, OFFICE/HOSPITAL VISITS MAY NOT BE BILLED WITH GLOBAL OB P 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5524

POSTPARTUM SERVICES MAY NOT BE BILLED WITH GLOBAL OB ON OR WITHIN 62 DAYS OF DE 20150715 22991231 19000101 22991231 97



5525

POSTPARTUM SERVICES MAY NOT BE BILLED WITH GLOBAL OB ON OR WITHIN 62 DAYS OF DE 20150715 22991231 19000101 22991231 97



5526MATERNITY GLOBAL/ANESTHESIA NEGATIVE CONTRA 20150715 22991231 19000101 22991231 97



5527MATERNITY GLOBAL/DELIVERY NEGATIVE CONTRA 20150715 22991231 19000101 22991231 97



5528

MATERNITY GLOBAL/ULTRASOUND NEGATIVE CONTRA 20150715 22991231 19000101 22991231 97



5529MATERNITY GLOBAL/URINALYSIS NEGATIVE CONTRA 20150715 22991231 19000101 22991231 97



5530MATERNITY GLOBAL/BLOOD TEST NEGATIVE CONTRA 20150715 22991231 19000101 22991231 97



5531

MATERNITY GLOBAL/ANTEPARTUM CARE NEGATIVE CONTRA 20150715 22991231 19000101 22991231 97



5600

PROCEDURE CANNOT BE BILLED ON THE SAME DAY AS CRITICAL CARE 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5601










5604PROCEDURE IS INCLUSIVE IN PRIMARY PROCEDURE. 20150715 22991231 19000101 22991231 97


Procedure code incidental to primary procedure.

5605PROCEDURE IS INCLUSIVE IN PRIMARY PROCEDURE. 20150715 22991231 19000101 22991231 97


Procedure code incidental to primary procedure.

5606PAYMENT MADE FOR SIMILAR PROCEDURE 20150715 22991231 19000101 22991231 97



5607PAYMENT MADE FOR SIMILAR PROCEDURE 20150715 22991231 19000101 22991231 97



5608

SAME PROVIDER CANNOT BILL APPLICATION/REMOVAL/REPAIR OF CAST FOR THE SAME RECIP 20150715 22991231 19000101 22991231 97



5609

SAME PROVIDER CANNOT BILL APPLICATION/REMOVAL/REPAIR OF CAST FOR THE SAME RECIP 20150715 22991231 19000101 22991231 97



5610

PROCEDURE CODES 95115, 95117 OR Z4998 SHALL NOT BE PAID ON THE SAME DAY AS PROC 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5611

PROFESSIONAL SERVICES ARE INCLUDED IN THE PROVISION OF THE EXTRACT. 20150715 22991231 19000101 22991231 97



5612

PROCEDURE CODES 95120-95134 WILL NOT BE PAID ON THE SAME DAY AS PROCEDURE CODES 20150715 22991231 19000101 22991231 97



5613

PROCEDURE CODES 95120-95134 WILL NOT BE PAID ON THE SAME DAY AS PROCEDURE CODES 20150715 22991231 19000101 22991231 97



5614

PROCEDURE NOT COVERED WHEN BILLED WITH PROCEDURE CODES 90918-90947 20150715 22991231 19000101 22991231 97



5615

PROCEDURE NOT COVERED WHEN BILLED WITH PROCEDURE CODES 90918-90947 20150715 22991231 19000101 22991231 97



5616

CRITICAL CARE CANNOT BE BILLED ON THE SAME DAY AS PROCEDURE 20150715 22991231 19000101 22991231 97



5617




5618

THE SAME PHYSICIAN MAY NOT BILL INTUBATION AND NEWBORN RESUSCITATION ON THE SAM 20150715 22991231 19000101 22991231 97



5619

THE SAME PHYSICIAN MAY NOT BILL INTUBATION AND NEWBORN RESUSCITATION ON THE SAM 20150715 22991231 19000101 22991231 97



5620

STANDBY/RESUCITATION/ATTENDANCE AT DELIVERY CANNOT BE BILLEDTOGETHER. 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5621

STANDBY/RESUCITATION/ATTENDANCE AT DELIVERY CANNOT BE BILLED TOGETHER. 20150715 22991231 19000101 22991231 97



5622

ELECTROSHOCK THERAPY MAY NOT BE ON THE SAME DAY AS A HOSPITAL VISIT 20150715 22991231 19000101 22991231 97



5623

ELECTROSHOCK THERAPY MAY NOT BE ON THE SAME DAY AS A HOSPITAL VISIT 20150715 22991231 19000101 22991231 97



5624

EMERGENCY ROOM VISIT/INITIAL HOSPITAL VISIT MAY NOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5625

EMERGENCY ROOM VISIT/INITIAL HOSPITAL VISIT MAY NOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5626

PROFESSIONAL COMPONENTS AND HOSPITAL VISITS MAY NOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5627

PROFESSIONAL COMPONENTS AND HOSPITAL VISITS MAY NOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5628

THE PAYMENT FOR THIS SERVICE WAS PREVIOUSLY MADE TO ANOTHER PROVIDER OR TO ANOT 20150715 22991231 19000101 22991231 B13

Previously paid. Payment for this claim/service may have been provided in a previous payment.

5629

THE PAYMENT FOR THIS SERVICE WAS PREVIOUSLY MADE TO ANOTHER PROVIDER OR TO ANOT 20150715 22991231 19000101 22991231 B13

Previously paid. Payment for this claim/service may have been provided in a previous payment.

5630

INCIDENTAL SURGERY MAY NOT BE BILLED WITH DEFINITIVE SURGERY ON THE SAME DAY. 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5631

INCIDENTAL SURGERY MAY NOT BE BILLED WITH DEFINITIVE SURGERY ON THE SAME DAY. 20150715 22991231 19000101 22991231 97



5632

EXPLORATORY LAP/LYSIS OF ADHESIONS MAY NOT BE BILLED ON THE SAME DAY WITH OTHER 20150715 22991231 19000101 22991231 97



5633

INCIDENTAL SURGERY NOT COVERED WITH DEFINITIVE SURGERY ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5634

THE SAME PHYSICAIN MAY NOT BILL HOSPITAL VISIT AND DISCHARGE VISIT ON THE SAME 20150715 22991231 19000101 22991231 97



5635

THE SAME PHYSICAIN MAY NOT BILL HOSPITAL VISIT AND DISCHARGE VISIT ON THE SAME 20150715 22991231 19000101 22991231 97



5636

HYSTERECTOMY ANCILLARY CODES MAY NOT BE PAID IN ADDITION TO THE HYSTERECTOMY P 20150715 22991231 19000101 22991231 97



5637

HYSTERECTOMY ANCILLARY CODES MAY NOT BE PAID IN ADDITION TO THE HYSTERECTOMY P 20150715 22991231 19000101 22991231 97



5638

HOSPITAL ADMISSION/VISITS MAY NOT BE BILLED ON OR AFTER OB GLOBAL 20150715 22991231 19000101 22991231 97



5639

HOSPITAL ADMISSION/VISITS MAY NOT BE BILLED ON OR AFTER OB GLOBAL 20150715 22991231 19000101 22991231 97



5640

SUBSEQUENT HOSPITAL CARE MAY NOT BE BILLED ON SAME DAY AS INITIAL HOSPITAL CARE 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5641

SUBSEQUENT HOSPITAL CARE MAY NOT BE BILLED ON SAME DAY AS INITIAL HOSPITAL CARE 20150715 22991231 19000101 22991231 97



5642

ROUTINE ANCILLARY SERVICES ASSOCIATED WITH AN ABORTION ARE COVERED IN THE TOTAL 20150715 22991231 19000101 22991231 97



5643

ROUTINE ANCILLARY SERVICES ASSOCIATED WITH AN ABORTION ARE COVERED IN THE TOTAL 20150715 22991231 19000101 22991231 97



5644

HOSPITAL VISITS AND SUBSEQUENT CRITICAL CARE MAY NOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5645

HOSPITAL VISITS AND SUBSEQUENT CRITICAL CARE MAY NOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5646

POST-OPERATIVE CARE IS INCLUDED IN THE SURGERY FEE AND CANNOT BE BILLED SEPARAT 20150715 22991231 19000101 22991231 97



5647

POST-OPERATIVE PHYSICIAN SERVICES FOR THE SAME DIAGNOSIS MAY NOT BE BILLED WITH 20150715 22991231 19000101 22991231 97



5648

PROCEDURE CODES NOT ALLOWED ON THE SAME DAY (95130- 95134) 20150715 22991231 19000101 22991231 97



5650

ONLY ONE OUTPATIENT OBSERVATION VISIT MAY BE BILLED PER DAY 20150715 22991231 19000101 22991231 97



5652

ONLY ONE INITIAL NICU PROCEDURE MAY BE BILLED PER HOSPITAL STAY. 20150715 22991231 19000101 22991231 119




Checkwrite End Date



5653SURGERY/CASTING & STRAPPING CONTRA 20150715 22991231 19000101 22991231 97



5654CASTING & STRAPPING/SURGERY CONTRA 20150715 22991231 19000101 22991231 97



5655 MULTIPLE SURGERY CONTRAS 20150715 22991231 19000101 22991231 97



5656




5658

A CARDIOLOGIST OR A RADIOLOGIST CANNOT BILL THIS PROCEDURE CODE ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5660

ONLY ONE HOSPITAL ADMISSION MAY BE BILLED PER HOSPITAL STAY 20150715 22991231 19000101 22991231 119



5661SUBSEQUENT CRITICAL CARE NOT VALID WITHOUT INITAL CARE. 20150715 22991231 19000101 22991231 97



5664

INITIAL OFFICE VISIT CANNOT BE BILLED ANYTIME WITHIN 3 YEARS OF A PRIOR VISIT 20150715 22991231 19000101 22991231 119

Benefit maximum for this time period or occurrence has been reached. N640

Exceeds number/frequency approved/allowed within time period.

5665

PRIOR VISIT CANNOT BE BILLED WITHIN 3 YEARS PRIOR TO AN INITIAL OFFICE VISIT 20150715 22991231 19000101 22991231 119



5666 NEW PATIENT/EXISTING PATIENT 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


5667 EXISTING PATIENT/NEW PATIENT 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640



Checkwrite End Date



5710

SERVICE CANNOT BE BILLED ON THE SAME DAY BY THE SAME PROVIDER 20150715 22991231 19000101 22991231 97



5711

SERVICE CANNOT BE BILLED ON THE SAME DAY BY THE SAME PROVIDER 20150715 22991231 19000101 22991231 97



5712

SERVICES CANNOT BE BILLED ON THE SAME DAY BY THE SAME PROVIDER 20150715 22991231 19000101 22991231 97



5713

SERVICES CANNOT BE BILLED ON THE SAME DAY BY THE SAME PROVIDER. 20150715 22991231 19000101 22991231 97



5714




5715




5716

SERVICES CANNOT BE BILLED ON THE SAME DAY FOR THE SAME RECIPIENT. 20150715 22991231 19000101 22991231 97



5717




5718

SERVICES CANNOT BE BILLED ON THE SAME DAY FOR THE SAME RECIPENT 20150715 22991231 19000101 22991231 97



5719

SERVICES CANNOT BE BILLED ON THE SAME DAY FOR THE SAME RECIPENT 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5720




5721




5722




5723




5726

THIS SERVICE IS NOT ALLOWED ON THE SAME DAY AS DAY TREATMENT 20150715 22991231 19000101 22991231 97



5727

THIS SERVICE IS NOT ALLOWED ON THE SAME DAY AS DAY TREATMENT 20150715 22991231 19000101 22991231 97



5728




5729




5730

THIS PROCEDURE CODE IS NOT COVERED WHEN BILLED WITH MEDICAL PSYCHOTHERAPY CODES 20150715 22991231 19000101 22991231 97



5731

THIS PROCEDURE CODE IS NOT COVERED WHEN BILLED WITH MEDICAL PSYCHOTHERAPY CODES 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5732

THE SAME PROVIDER MAY NOT BILL HOSPITAL VISITS/PSYCHOTHERAPY ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5733

THE SAME PROVIDER MAY NOT BILL HOSPITAL VISITS/PSYCHOTHERAPY ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5734

THE SAME PROVIDER MAY NOT BILL PSYCHOTHERAPY/OFFICE VISITS ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5735

THE SAME PROVIDER MAY NOT BILL PSYCHOTHERAPY/OFFICE VISITS ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5736




5738

SERVICES CANNOT BE BILLED ON THE SAME DAY FOR THE SAME RECIPIENT 20150715 22991231 19000101 22991231 97



5750

PROCEDURE NOT COVERED WHEN BILLED WITH 76805, 76810 OR 76816 ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5751

PROCEDURE NOT COVERED WHEN BILLED WITH 76805, 76810 OR 76816 ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5752

PROCEDURE NOT COVERED WHEN BILLED WITH 76805 ON THE SAME DAY 20150715 22991231 19000101 22991231 97



5753

PROCEDURE NOT COVERED WHEN BILLED WITH 76805 ON THE SAME DAY 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5754

OUR RECORDS INDICATE THAT THIS SERVICE HAS ALREADY BEEN PERFORMED ON THIS PATIE 20150715 22991231 19000101 22991231 97



5755

OUR RECORDS INDICATE THAT THIS SERVICE HAS ALREADY BEEN PERFORMED ON THIS PATIE 20150715 22991231 19000101 22991231 97



5760 ESWL PRICING 20150725 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. N524


5770

INDEPENDENT RURAL HEALTH CLINICS CANNOT BE PAID FOR MORE THAN ONE SERVICE PER D 20150715 22991231 19000101 22991231 97



5790PHYSICAL THERAPY ELECTRIC STIMULATION CONTRA 20150715 22991231 19000101 22991231 97






5792PHYSICAL THERAPY APPLIANCES CONTRA 20150715 22991231 19000101 22991231 97



5800

RESIDENTIAL SERVICES AND RESPITE ,PERSONAL CARE/COMPANION CARE NOT ALLOWED FOR 20150715 22991231 19000101 22991231 97



5801

RESIDENTIAL SERVICES AND RESPITE ,PERSONAL CARE/COMPANION CARE NOT ALLOWED FOR 20150715 22991231 19000101 22991231 97



5802

PREVOCATIONAL SERVICES AND SUPPORTED EMPLOYMENT SHALL NOT BE PAID ON THE SAME D 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5803

PREVOCATIONAL SERVICES AND SUPPORTED EMPLOYMENT SHALL NOT BE PAID ON THE SAME D 20150715 22991231 19000101 22991231 97



5804

ONLY ONE TYPE OF RESPITE CARE IS ALLOWED FOR A GIVEN DATE OF SERVICE. 20150715 22991231 19000101 22991231 97



5805

OUR RECORDS SHOW THIS WAVIER SERVICE HAS ALREADY BEEN PAID FOR THE DATE OF SERV 20171001 22991231 20171001 22991231 18


5811HEARING AND VISION SCREENING REQUIRE EP MODIFIER. 20150715 22991231 19000101 22991231 4


5812

POST-CATARACT FOLLOW-UP CARE HAS BEEN PAID TO THE SURGEON ORPOST-CATARACT FOLLO 20150715 22991231 19000101 22991231 4


5813

POST-CATARACT FOLLOW-UP CARE HAS BEEN PAID TO THE SURGEON ORPOST-CATARACT FOLLO 20150715 22991231 19000101 22991231 4


5814PROCEDURE NOT COVERED WITH SPECIFIC CODES. 20150715 22991231 19000101 22991231 97



5815

VISION AND HEARING SCREENING MUST BE BILLED WITH A REGULAR SCREENING AND ARE LI 20150715 22991231 19000101 22991231 97



5816

HIV CODES MUST BE BILLED IN CONJUNCTION WITH FAMILY PLANNING CODES. 20150715 22991231 19000101 22991231 97



5817

REVENUE CODES 170 -171 MUST NOT EXCEED 10 UNITS UNDER MOTHER'S NUMBER. 20150715 22991231 19000101 22991231 119



5818THERAPY CODE PAYABLE ONLY WITH THERAPEUTIC TREATMENT. 20150715 22991231 19000101 22991231 97




Checkwrite End Date



5819

OBSERVATION MUST BE BILLED IN CONJUNCTION WITH FACILITY FEE. 20150715 22991231 19000101 22991231 97



5820LTC VENT CANNOT BE BILLED WITHOUT LTC STAY 20150715 22991231 19000101 22991231 97



5821ADD - ON CODE CANNOT BE PAID WITHOUT PAID PRIMARY CODE 20150715 22991231 19000101 22991231 97



5822AVASTIN J9035 NEGATIVE CONTRA 20150715 22991231 19000101 22991231 49

This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N390


5823PACE NH DEPENDENT ON PACE NON-NH BILLING 20150715 22991231 19000101 22991231 4


5825 FP OUTPT LARC REQIURES INPT 20150715 22991231 19000101 22991231 97



5830

PROCEDURE IS NOT PAYABLE WHEN BILLED WITHOUT A PAID ROOT CANAL FOR THE SAME TOO 20150715 22991231 19000101 22991231 97



5831

MEDICAID'S RECORD DO NOT SHOW A ROOT CANAL PAYMENT THEREFORE THIS PROCEDURE COD 20150715 22991231 19000101 22991231 97



5832

MEDICAID'S RECORD DO NOT SHOW A ROOT CANAL PAYMENT THEREFORE THIS PROCEDURE COD 20150715 22991231 19000101 22991231 97



5900

NCCI-MUE - UNITS OF SERVICE EXCEED MUE. RECIPIENT CANNOT BE BILLED. 20160501 22991231 19000101 22991231 273 Coverage/program guidelines were exceeded. N362



Checkwrite End Date



5910

NCCI - SERVICE NOT PAYABLE WITH ANOTHER SERVICE ON THIS CLAIM. RECIPIENT CANNOT 20150715 22991231 19000101 22991231 236

This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.

5911

NCCI - SERVICE NOT PAYABLE WITH ANOTHER SERVICE ON ANOTHER CLAIM. RECIPIENT CAN 20150715 22991231 19000101 22991231 236


5912



5920

NCCI - SERVICE NOT PAYABLE WITH ANOTHER SERVICE ON THIS CLAIM. RECIPIENT CANNOT 20150715 22991231 19000101 22991231 236


5921



5922



5930

NCCI- SVC IS A DUPE OF A PREVIOUSLY DENIED NCCI SVC. RECIPIENT CANNOT BE BILLED 20150715 22991231 19000101 22991231 97



5940

NCCI -SERVICE NOT PAYABLE WITH ANOTHER SERVICE ON THIS CLAIM. RECIPIENT CANNOT 20150715 22991231 19000101 22991231 236



Checkwrite End Date



5941



5942



6001

THIS AMBULANCE SERVICE PROCEDURE CODE IS LIMITED TO FOUR UNITS PER CALENDAR MON 20150715 22991231 19000101 22991231 119



6010

INPATIENT/OUTPATIENT/ASC VISITS HAVE BEEN EXCEEDED FOR THE CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6020HEARING AID REPAIR IS LIMITED TO TWO EVERY SIX MONTHS. 20150715 22991231 19000101 22991231 119



6021

MONAURAL HEARING AID BATTERIES ARE LIMITED TO ONE PACKAGE EVERY TWO MONTHS. 20150715 22991231 19000101 22991231 119



6022

MONAURAL EARMOLDS ARE LIMITED TO ONE EVERY FOUR MONTHS. 20150715 22991231 19000101 22991231 119



6023HEARING AID REPAIR IS LIMITED TO ONCE EVERY SIX MONTHS 20150715 22991231 19000101 22991231 119



6024

THE PURCHASE OF A HEARING AID STETHOSCOPE IS LIMITED TO ONE EVERY TWO YEARS. 20150715 22991231 19000101 22991231 119



6025EARMOLDS ARE LIMITED TO TWO EVERY FOUR MONTHS. 20150715 22991231 19000101 22991231 119



6026

BINAURAL HEARING AID BATTERIES ARE LIMITED TO TWO PACKAGES EVERY TWO MONTHS. 20150715 22991231 19000101 22991231 119



6030

NEW PATIENT CODE Z5147 MAY ONLY BE BILLED ONCE PER LIFETIME PER RECIPIENT 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached. N117

This service is paid only once in a patient's lifetime.

6040PERIAPICAL XRAYS - LIMIT 5 PER CAL YEAR 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6041

THE CALENDAR YEAR LIMIT HAS BEEN EXCEEDED FOR THIS PROCEDURE 20150715 22991231 19000101 22991231 119



6042PROCEDURE LIMITED TO ONCE EVERY 30 DAYS. 20150715 22991231 19000101 22991231 119



6043

THE CALENDAR YEAR LIMIT HAS BEEN EXCEEDED FOR THIS PROCEDURE 20150715 22991231 19000101 22991231 119



6044

EMERGENCY ORAL EXAM (D0140) LIMITED TO ONCE PER CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6045DENTAL SERVICE LIMITED TO ONCE PER TOOTH/PER LIFETIME. 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached. N117


6046PROCEDURE CODE LIMITED TO ONCE EVERY SIX MONTHS 20150715 22991231 19000101 22991231 119



6047PROPHYLAXIS IS LIMITED TO ONCE EVERY 6 MONTHS 20150715 22991231 19000101 22991231 119



6048FLUORIDE IS LIMITED TO ONCE EVERY 6 MONTHS 20150715 22991231 19000101 22991231 119



6049PROCEDURE LIMITED TO TWO PER LIFETIME PER TOOTH. 20150715 22991231 19000101 22991231 119



6050

PROCEDURE CODE IS LIMITED TO ONE OCCURANCE EVERY SIX MONTHS 20150715 22991231 19000101 22991231 119



6051

FULL SERIES/PANORAMIC X-RAYS ARE LIMITED TO ONE EVERY THREE CALENDAR YEARS 20150715 22991231 19000101 22991231 119



6052

CODE, SERVICE, PROCEDURE, NDC OR STAY REQUIRES PRIOR AUTHORIZATION 20150715 22991231 19000101 22991231 16



6053

COMPREHENSIVE DENTAL EXAM MAY ONLY BE BILLED ONCE PER LIFETIME PER PROVIDER. 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached.

6054ORAL EVALUATION < 3 YRS (D0145) 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6056FLOURIDE VARNISH < 3YRS - LIMIT 3 PER CAL YEAR 20150715 22991231 19000101 22991231 119



6057FLOURIDE VARNISH < 3YRS - LIMIT 6 TOTAL 20150715 22991231 19000101 22991231 119



6058FLOURIDE VARNISH > 3YRS - LIMIT 1 PER CAL YEAR 20150715 22991231 19000101 22991231 119



6059FLOURIDE VARNISH FREQ < 3 YRS - LIMIT 1 PER 90 DAYS 20150715 22991231 19000101 22991231 119



6060DENTAL BITEWING X-RAYS - LIMIT 1 PER 6 CAL MO 20150715 22991231 19000101 22991231 119



6061DENTAL PROCEDURE LIMIT - 1 PER DATE OF SERVICE 20150715 22991231 19000101 22991231 119



6062DENTAL CROWNS LIMITED TO 6 PER DAY 20160608 22991231 19000101 22991231 119



6063DENTAL CORE LIMITED TO 6 PER DAY 20160608 22991231 19000101 22991231 119



6064DENTAL PULPAL THERAPY LIMITED TO 6 PER DAY 20160608 22991231 19000101 22991231 119



6065DENTAL ENDONTIC THERAPY LIMITED TO 6 PER DAY 20160608 22991231 19000101 22991231 119



6066DENTAL RESTORATION LIMIT 1 PER 6 MONTHS SAME TOOTH 20150715 22991231 20150715 22991231 119



6067DENTAL RESTORATION LIMIT 1 PER 12 MO SAME SURFACE 20150715 22991231 20150715 22991231 119



6070

DENTAL PERIAPICAL X-RAYS LIMITED WHEN USED WITH BITEWING 20150715 22991231 20150715 22991231 117

Transportation is only covered to the closest facility that can provide the necessary care. N115

This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.

6100DME PROCEDURE LIMITED TO 60 PER CALENDAR MONTH 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6101DME PROCEDURE LIMIT TO 20 PER CALENDAR MONTH 20150715 22991231 19000101 22991231 119



6102DME PROCEDURE LIMITED TO 1 PER 5 CALENDAR YEARS 20150715 22991231 19000101 22991231 119



6103PROCEDURE IS LIMITED TO THIRTY (30) PER MONTH. 20150715 22991231 19000101 22991231 119






6105DME CLOSED POUCH TOTAL LIMIT OF 60 PER CAL MONTH 20150715 22991231 19000101 22991231 119



6106PROCEDURE IS LIMITED TO 30 (THIRTY) PER MONTH 20150715 22991231 19000101 22991231 119






6108DME WC PRESSURE PAD TOTAL LIMIT OF 1 PER CAL YEAR 20150715 22991231 19000101 22991231 119



6109PROCEDURE CODE IS LIMTED TO 100 PER MONTH 20150715 22991231 19000101 22991231 119



6110

THE LIMIT OF TWO UNITS PER MONTH HAS BEEN EXCEEDED FOR THIS PROCEDURE 20150715 22991231 19000101 22991231 119



6111

THE LIMIT OF THREE UNITS PER MONTH HAS BEEN EXCEEDED FOR THIS PROCEDURE. 20150715 22991231 19000101 22991231 119



6112

THE LIMIT OF TWO UNITS PER MONTH HAS BEEN EXCEEDED FOR THIS PROCEDURE. 20150715 22991231 19000101 22991231 119



6113DME CODES LIMITED TO THIRTY-ONE UNITS PER MONTH 20150715 22991231 19000101 22991231 119



6114DME PROCEDURE LIMITED TO 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6115

MEDICAL SUPPLIES LIMIT IS $1,800.00 PER WAIVER YEAR, 02/22-02/21. THE LIMIT HA 20150715 22991231 19000101 22991231 119







Checkwrite End Date






6118

THE LIMIT OF TWO UNITS PER MONTH HAS BEEN EXCEEDED FOR THIS PROCEDURE 20150715 22991231 19000101 22991231 119



6120THIS PROCEDURE CODE IS LIMITED TO ONE PER MONTH. 20150715 22991231 19000101 22991231 119






6122LEG BAGS ARE LIMITED TO TWO PER MONTH 20150715 22991231 19000101 22991231 119





































Checkwrite End Date





















6140

DME PROCEDURE RENTAL LIMITED TO 1 PER CALENDAR MONTH 20150715 22991231 19000101 22991231 119



6141




6142




6143DME BATTERY CHARGER TOTAL LIMIT OF 1 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6144DME BATTERY TOTAL LIMIT OF 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6145DME NON-INSULIN PROC LIMIT OF 2 PER 3 CAL MO 20150715 22991231 19000101 22991231 119



6146DME NON-INSULIN PROC LIMIT OF 1 PER 3 CAL MO 20150715 22991231 19000101 22991231 119



6147DME INSULIN PROC LIMIT OF 4 PER CAL MO 20150715 22991231 19000101 22991231 119










Checkwrite End Date



6150VISION AND HEARING SCREENING ONE PER YEAR 20150715 22991231 19000101 22991231 119



6151INITIAL SCREENING IS LIMITED TO ONCE PER LIFETIME 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached. N117


6152EPSDT SCREENING LIMIT HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6153EPSDT SCREENING LIMIT HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6154MAXIMUN UNIT LIMIT HAS BEEN EXCEEDED. 20150715 22991231 19000101 22991231 119



6155EPSDT SCREENING LIMIT HAS BEEN EXCEEDED. 20150715 22991231 19000101 22991231 119



6179THE ALLOWED EYE EXAM LIMITATION HAS BEEN EXCEEDED. 20150715 22991231 19000101 22991231 119



6180THE ALLOWED LENS LIMITATION HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6181THE ALLOWED LENS LIMITATION HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6182THE ALLOWED FRAMES LIMITATION HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6183THE ALLOWED EYE EXAM LIMITATION HAS BEEN EXCEEDED. 20150715 22991231 19000101 22991231 119



6184THE ALLOWED FITTING LIMITATION HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6185 EYE LENS LIMIT LESS THAN 21 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6186 EYE FRAME LIMIT LESS THAN 21 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6187 EYE EXAM LIMIT LESS THAN 21 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6188 EYE FITTING LIMIT LESS THAN 21 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6189EYE EXAM LIMIT 1 PER 3 YR (21 AND OLDER) 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6190EYE REFRACTION LIMIT 1 PER 3 YR (21 AND OLDER) 20150715 22991231 19000101 22991231 119



6191EYE REFRACTION LIMIT LESS THAN 21 20150715 22991231 19000101 22991231 119



6192 EYE REFRACTION LIMIT 1 PER 2 YEARS (21 AND OLDER) 20150715 22991231 19000101 22991231 119



6193EYE EXAM LIMIT 1 PER 3 YR (21 AND >) 20150715 22991231 19000101 22991231 119



6194EYE REFRACTION LIMIT 1 PER 3 YR (21 AND > ) 20150715 22991231 19000101 22991231 119



6195EYE FRAME LIMIT 1 PER 3 YR (21 AND >) 20150715 22991231 19000101 22991231 119



6196EYE LENS LIMIT 1 PER 3 YR (21 AND >) 20150715 22991231 19000101 22991231 119



6197EYE FITTING LIMIT 1 PER 3 YR (21 AND >) 20150715 22991231 19000101 22991231 119



6200

THIS PROCEDURE IS LIMITED TO SIXTEEN (16) UNITS PER CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6201

FAMILY PLANNING PERIODIC FOLLOW-UP IS LIMITED TO FOUR (4) VISITS PER YEAR. 20150715 22991231 19000101 22991231 119



6202THE YEARLY LIMIT FOR THIS PROCEDURE HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6203THIS PROCEDURE IS LIMITED TO ONE PER POSTPARTUM PERIOD. 20150715 22991231 19000101 22991231 119



6204

INITIAL VISIT IS LIMITED TO ONE PER RECIPIENT, PER PROVIDER, PER LIFETIME 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached.

6205

THIS PROCEDURE CODE IS LIMITED TO ONE EVERY CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6206

PROCEDURE CODE 11795 IS LIMITED TO ONE EVERY 365 DAYS AND PROCEDURE CODE 11977 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6207

THESE NORPLANT SERVICES MUST BE BILLED USING THE APPROPRIATE COMBINATION CODE O 20150715 22991231 19000101 22991231 97



6208PROCEDURE IS LIMITED TO ONE SERVICE EVERY 70 DAYS. 20150715 22991231 19000101 22991231 119



6209

PROCEDURE LIMITED TO ONE SERVICE DURING 60 (SIXTY) DAY POSTPARTUM PERIOD. 20150715 22991231 19000101 22991231 119



6210RADIOLOGY - LEVONORGESTREL IU LIMIT - 1 PER 5 YRS 20150715 22991231 19000101 22991231 119



6211

DEPO-PROVERA INJECTION LIMITED TO ONE PER EVERY 70 DAYS. 20150715 22991231 19000101 22991231 119



6212FP-LEVONORGESTREL-IU LIMIT-1 PER 3 YRS 20150715 22991231 19000101 22991231 119



6213PROCEDURE W/UA MODIFIER IS LIMITED TO 4 EVERY 12 MONTHS 20171001 22991231 20171001 22991231 119



6214

PROCEDURE W/UB, UC, UD MODIFIER IS LIMITED TO 12 EVERY CALENDAR MONTHS 20171001 22991231 20171001 22991231 119



6230

MORE THAN ONE MEDICAL ENCOUNTER (Z5298) CANNOT BE PAID ON THE SAME DATE OF SERV 20150715 22991231 19000101 22991231 97



6231

MORE THAN ONE DENTAL ENCOUNTER (D9430)CANNOT BE PAID ON THE SAME DATE OF SERVIC 20150715 22991231 19000101 22991231 97



6240 HBO LIMIT HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640









Checkwrite End Date















6260NUMBER OF HOME HEALTH VISITS EXCEED LIMIT 20150715 22991231 19000101 22991231 119



6270 HOSPICE ONE (1) UNIT PER DAY 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6280

THE LIMIT FOR THESE SERVICES HAS BEEN REACHED FOR THE CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6281

OUTPATIENT VISITS HAVE BEEN EXCEEDED FOR THIS CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6282

INPATIENT DAYS HAVE BEEN EXEEDED FOR THIS CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6283

REVENUE CODES 170 -171 MUST NOT EXCEED 10 UNITS PER NEWBORN UNDER MOTHER'S NUMB 20150715 22991231 19000101 22991231 119



6284 MEPD FISCAL YEAR DOLLAR LIMIT 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6285HOSPITAL EMERG LIMIT 3 DAYS PER ADMIT 20150715 22991231 19000101 22991231 119



6290

MULTIPLE URINALYSIS TESTS CANNOT BE BILLED ON THE SAME DAY 20150715 22991231 19000101 22991231 97




Checkwrite End Date



6291SPECIMEN COLLECTION FEE IS LIMITED TO ONE PER DAY 20150715 22991231 19000101 22991231 119



6292LAB DRUG SCREENING LIMIT OF 1 PER DAY 20150715 22991231 19000101 22991231 119



6293LAB ?DRUG SCREENING LIMIT OF 1 EVERY 7 DAYS 20150715 22991231 19000101 22991231 119



6300THIS PROCEDURE IS LIMITED TO 12 UNITS EVERY 24 MONTHS. 20150715 22991231 19000101 22991231 119



6301

MORE THAN ONE OBSTETRICAL DELIVERY CODE MAY NOT BE BILLED W ITHIN SIX MONTHS 20150715 22991231 19000101 22991231 119



6302

MORE THAN THREE OFFICE VISITS MAY NOT BE BILLED WITH PREGNANCY DIAGNOSIS. 20150715 22991231 19000101 22991231 119



6303

MORE THAN ONE OBSTETRICAL DELIVERY CODE MAY NOT BE BILLED WITHIN SIX MONTHS. 20150715 22991231 19000101 22991231 119



6304OBSTETRICAL CARE LIMIT FOR SPECIALTY 921 20150715 22991231 19000101 22991231 119



6305 ES - VAGINAL DELIVERY LIMIT 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6306 ES - C-SECTION LIMIT LIMIT 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6307PRENATAL OFFICE VISIT LIMIT PERINATOLOGIST 20150715 22991231 19000101 22991231 119



6308

TOBACCO CESSATION COUNSELING LIMIT 4 PER 12 MONTHS 20150715 22991231 19000101 22991231 119



6309TOBACCO CESSATION COUNSELING LIMIT 1 PER DAY 20150715 22991231 19000101 22991231 119



6310

THE QUANTITY DISPENSED EXCEEDS THE MAXIMUM QUANTITY ALLOWED FOR THE DRUG CODE P 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6311QTY DISPENSED EXCEEDS MAX QTY BASED ON PA 20150715 22991231 19000101 22991231 16



6312MONTHLY SCRIPT LIMIT EXCEEDED 20150715 22991231 19000101 22991231 119



6313MONTHLY SCRIPT LIMIT EXCEEDED - BRANDED DRUG 20150715 22991231 19000101 22991231 119









6316MONTHLY BRAND SCRIPT LIMIT EXCEEDED 20150715 22991231 19000101 22991231 119









6319MONTHLY TOTAL SCRIPT LIMIT EXCEEDED 20150715 22991231 19000101 22991231 119



6320MONTHLY MAXIMUM SCRIPT LIMIT EXCEEDED 20150715 22991231 19000101 22991231 119



6330RECIPIENT HAS RESERVE MEDICINE THAT EXCEEDS LIMIT 20150715 22991231 19000101 22991231 119



6331PHARMACY STABLE THERAPY REQUIREMENT NOT MET 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

6332PHARMACY STABLE THERAPY REQUIREMENT NOT MET 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

6340DRUG SCREEN DAILY MAX FOR PRESENCE OF DRUGS 20171001 22991231 20171001 22991231 119



6341DRUG SCREEN DAILY MAX FOR G-CODE(S) IS LIMITED TO 1 PER DAY 20171001 22991231 20171001 22991231 119




Checkwrite End Date



6350DME GESTATIONAL INSULIN LIMIT 4 BOXES PER MONTH 20150715 22991231 19000101 22991231 119



6351DME GESTATIONAL INSULIN LIMIT 2 BOXES PER MONTH 20150715 22991231 19000101 22991231 119



6400SPECIMEN COLLECTION FEE IS LIMITED TO ONE PER DAY 20150715 22991231 19000101 22991231 97



6401

OB ULTRASOUND LIMIT HAS BEEN REACHED FOR THIS RECIPIENT. ANY FURTHER WILL REQUI 20150715 22991231 19000101 22991231 119



6402SCREENING MAMMOGRAPHY IS LIMITED TO ONE PER YEAR 20150715 22991231 19000101 22991231 119



6403

THE LIMIT FOR THESE SERVICES HAS BEEN REACHED FOR THE CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6404

PROCEDURE IS LIMITED TO ONCE EVERY THIRTY(30) DAYS BY THE SAME BILLING PROVIDER 20150715 22991231 19000101 22991231 119



6405

PROCEDURE CODE IS LIMITED TO ONE OCCURENCE EVERY SIX MONTHS 20150715 22991231 19000101 22991231 119



6406NEWBORN CODE MAY NOT BE BILLED MORE THAN ONCE 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached. N117


6407

THE SAME PROVIDER MAY NOT BILL MORE THAN ONE NEW PATIENT OFFICE VISIT PER RECIP 20150715 22991231 19000101 22991231 119



6408PHYSICIAN IS LIMITED TO ONE VISIT PER DAY PER RECIPIENT 20150715 22991231 19000101 22991231 97



6409REQUESTED INPATIENT HOSPITAL SERVICES EXCEED LIMIT OF 16 20150715 22991231 19000101 22991231 119



6410PHYSICIAN OFFICE VISIT LIMITATION HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119



6411INITIAL CRITICAL CARE LIMITED TO ONE PER DAY 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6412ER AND CRITICAL CARE CODE ONE PER CLAIM. 20150715 22991231 19000101 22991231 97



6413REQUESTED INPATIENT HOSPITAL SERVICES EXCEED LIMIT OF 16 20150715 22991231 19000101 22991231 119



6416EMG PROCEDURE LIMIT TO 4 PER CAL YR 20150715 22991231 19000101 22991231 119



6418OB ULTRASOUND YEARLY LIMIT PERINATOLOGISTS 20150715 22991231 19000101 22991231 119






6511

THE YEARLY LIMIT FOR THIS PROCEDURE HAS BEEN EXCEEDED. 20150715 22991231 19000101 22991231 119



6512




6513




6514THIS PROCEDURE IS LIMITED TO 5 UNITS PER YEAR. 20150715 22991231 19000101 22991231 119



6515THIS PROCEDURE IS LIMITED TO ONE EPISODE A YEAR 20150715 22991231 19000101 22991231 119



6516THIS PROCEDURE IS LIMITED TO 52 UNITS PER YEAR 20150715 22991231 19000101 22991231 119



6517THIS PROCEDURE IS LIMITED TO 10 (TEN) UNITS PER YEAR 20150715 22991231 19000101 22991231 119



6518PROCEDURE CODE IS LIMITED TO 104 UNITS A YEAR. 20150715 22991231 19000101 22991231 119



6519PROCEDURE CODE IS LIMITED TO 104 TIMES PER YEAR 20150715 22991231 19000101 22991231 119



6520PROCEDURE CODE IS LIMITED TO 104 TIMES A YEAR. 20150715 22991231 19000101 22991231 119



6521THIS PROCEDURE IS LIMITED TO 365 EPISODES A YEAR. 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6522THIS PROCEDURE IS LIMITED TO 52 UNITS A YEAR. 20150715 22991231 19000101 22991231 119



6523BENEFITS HAVE BEEN EXCEEDED FOR THE CALDEAR YEAR. 20150715 22991231 19000101 22991231 119



6524BENEFITS HAVE BEEN EXCEEDED FOR THE CALENDAR YEAR. 20150715 22991231 19000101 22991231 119









6527BENEFITS HAVE BEEN EXCEEDEF FOR THE CALENDAR YEAR. 20150715 22991231 19000101 22991231 119






6529PROCEDURE IS LIMITED TO 260 UNITS A YEAR. 20150715 22991231 19000101 22991231 119






6531PROCEDURE CODE IS LIMITED TO 312 UNITS A YEAR. 20150715 22991231 19000101 22991231 119






6533PROCEDURE IS LIMITED TO 1040 UNITS A YEAR 20150715 22991231 19000101 22991231 119






6535PROCEDURE IS LIMITED TO 130 UNITS A CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6536PROCEDURE IS LIMITED TO 104 TIMES A CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6537PROCEDURE IS LIMITED TO 365 TIMES A CALENDAR YEAR. 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6538

YEARLY LIMIT FOR CRISIS INTERVENTION HAS BEEN EXCEEDED 20150715 22991231 19000101 22991231 119






6540

PSYCHOTHERAPY SERVICES ARE LIMITED TO 12 (TWELVE) PER CALENDAR YEAR AT PLACE OF 20150715 22991231 19000101 22991231 119



6541

DIAGNOSTIC ASSESSMENTS ARE LIMITED TO ONE ENCOUNTER PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119






6543PSYCHOLOGY/REHAB - PSYCHOLOGY DX TESTING 20150715 22991231 19000101 22991231 119



6544PSYCHOLOGY/REHAB - NEUROPSYCHOLOGY DX TESTING 20150715 22991231 19000101 22991231 119



6546PSYCHOLOGY/REHAB - PPSYCHOLOGY LIMIT 52 A YEAR 20150715 22991231 19000101 22991231 119



6547PSYCHOLOGY/REHAB - INDIVIDUAL THERAPY 1 PER WEEK 20150715 22991231 19000101 22991231 119



6548PSYCHOLOGY/REHAB - GROUP THERAPY 1 PER WEEK 20150715 22991231 19000101 22991231 119



6549

MENTAL HEALTH NON-EMERGENCY TRANSPORATION LIMIT 20150715 22991231 19000101 22991231 119



6550PROCEDURE IS LIMITED TO 2 UNITS PER QUARTER 20150715 22991231 19000101 22991231 119



6600RADIOLOGY & CARDIOLOGY - PROCEDURE REQUIRES PA 20150715 22991231 19000101 22991231 119



6610

DIALYSIS ULTRAFILTRATION CODES Z5256 AND Z5266 ARE LIMITED TO A TOTAL OF 3 PER 20150715 22991231 19000101 22991231 119



6611PROCEDURE CODE IS LIMITED TO 156 UNITS PER CALENDAR YEAR. 20150715 22991231 19000101 22991231 119



6612

PROCEDURE CODE IS LIMITED TO ONE UNIT PER CALENDAR MONTH. 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6613PROCEDURE CODE IS LIMITED TO 12 UNITS PER LIFETIME. 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached.

6630

THIS PROCEDURE CODE IS LIMITED TO ONE PER CALENDAR MONTH. 20150715 22991231 19000101 22991231 119



6640




6641




6642




6643




6644




6645




6646







6650

THE LIMIT FOR THESE SERVICES HAS BEEN REACHED FOR THIS CONTRACT YEAR 20150715 22991231 19000101 22991231 119



6651

UNITS BILLED FOR PROCEDURE CODE EXCEED MAXIMUM UNITS ALLOWED 20150715 22991231 19000101 22991231 119



6652

UNITS BILLED FOR PROCEDURE CODE EXCEED MAXIMUM UNITS ALLOWED 20150715 22991231 19000101 22991231 119



6653

PROCEDURE LIMITED TO 1080 HOURS,PER WAIVER YEAR OCTOBER 1 - SEPTEMBER 30. 20150715 22991231 19000101 22991231 119



6654LAHWV - LIMITED $1000 PER WAIVER YEAR 20150715 22991231 19000101 22991231 119



6655LAHWV-TRANSPORTATION LIMITED $1000 PER WAIVER YEAR 20150715 22991231 19000101 22991231 119



6656PERSONAL CARE BACHELORS DEGREE LIMIT 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6657PERSONAL CARE MASTERS DEGREE LIMIT 20150715 22991231 19000101 22991231 119



6658 SPEECH/HEARING THERAPY LIMIT 20150715 22991231 19000101 22991231 119Benefit maximum for this time period or occurrence has been reached. N640


6659WAIVER SERVICE LIMITED TO $1800 PER WAIVER YEAR 20151215 22991231 19000101 22991231 119






6661PACE GLOBAL FEE LIMITED TO ONE PER MONTH 20150715 22991231 19000101 22991231 119









6664

WAIVER - PROF & TECH THERAPEUTIC BEHAVIOR LIMITED TO 1200 UNITS 20151215 22991231 19000101 22991231 119



6665

WAIVER - PROFESSIONAL THERAPEUTIC BEHAVIOR LIMITED TO 800 UNITS 20151215 22991231 19000101 22991231 119






6671

OUR RECORDS INDICATE THAT THIS SERVICE HAS ALREADY BEEN PERFORMED ON THIS RECIP 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached. N117


6672

OUR RECORDS INDICATE THAT THIS SERVICE HAS ALREADY BEEN PERFORMED ON THIS PATIE 20150715 22991231 19000101 22991231 35 Lifetime benefit maximum has been reached.

6673PROCEDURE IS LIMITED TO ONE (1) EVERY TWO YEARS. 20150715 22991231 19000101 22991231 119



6674CLAIM STILL IN PROCESS. PLEASE DO NOT REBILL. 20150715 22991231 19000101 22991231 18


6677

PROCEDURE CODE CANNOT BE BILLED MORE THAN SIX(6) TIMES WITH THE SAME MODIFIER. 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6690

REVENUE CODE 183 IS LIMITED TO 6 DAYS EACH CALENDAR QUARTER. 20150715 22991231 19000101 22991231 119



6691

REVENUE CODE 184 IS LIMITED TO 14 DAYS PER CALENDAR MONTH 20150715 22991231 19000101 22991231 119



6700DME PROCEDURE LIMITED TO 1 PER 8 CAL YRS 20150715 22991231 19000101 22991231 119



6701DME PROCEDURE LIMIT TO 1 PER DAY 20150715 22991231 19000101 22991231 119



6702DME PROCEDURE LIMIT TO 1 PER CALENDAR WEEK 20150715 22991231 19000101 22991231 119


















6708DME PROCEDURE LIMIT TO 2 PER 3 CALENDAR MONTHS 20150715 22991231 19000101 22991231 119



6709DME PROCEDURE LIMIT TO 3 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119









6712DME PROCEDURE LIMIT TO 2 PER CALENDAR YEARS 20150715 22991231 19000101 22991231 119







Checkwrite End Date






6715DME PROCEDURE LIMIT TO 2 PER CALENDAR YEARS 20150715 22991231 19000101 22991231 119












6719DME PROCEDURE LIMITED TO (1) PER 8 CALENDAR YEARS 20150715 22991231 19000101 22991231 119



6720DME PROCEDURE LIMIT TO 1 PER CALENDAR 7 YEARS 20150715 22991231 19000101 22991231 119



6721DME REPAIRS LIMITED $1000 PER DAY 20150715 22991231 19000101 22991231 119



6722DME POWER TIRES LIMIT 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6723DME BACK CUSHIONS LIMIT 1 PER 2 CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6724DME SEAT CUSHIONS LIMIT 1 PER 1 CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6725DME FOOTREST LIMIT 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6726DME ARMREST LIMIT 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6727DME HEADREST LIMIT 1 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6728DME SAFETY VEST LIMIT 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6729DME MANUAL TIRES LIMIT 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119




Checkwrite End Date



6730DME MANUAL CASTERS LIMIT 2 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6731DME POWER CASTERS LIMIT 4 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



6732DME GENERAL CUSHION LIMIT 1 PER CALENDAR YEAR 20150715 22991231 19000101 22991231 119



7000 CLAIM FAILED A PRODUR ALERT 20150715 22991231 19000101 22991231 175 Prescription is incomplete.

7001 INFORMATIONAL PRODUR ALERT 20150715 22991231 19000101 22991231 175 Prescription is incomplete.

7002CLAIM DENIED FOR PRODUR REASONS 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

7003PRODUR ALERT REQUIRES PA FOR OVERRIDE 20150715 22991231 19000101 22991231 175 Prescription is incomplete.

7004NON-OVERRIDEABLE PRODUR ALERT 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

7101ADMIT DATE LESS THAN FIRST DATE OF SERVICE 20140101 22991231 19000101 22991231 16



7102TYPE OF BILL INDICATES LATE CHARGES 20140101 22991231 19000101 22991231 16



7103INTERIM CLAIM LESS THAN MINIMUM STAY 20140101 22991231 19000101 22991231 16




Checkwrite End Date



7104INTERIM CLAIM PATIENT STATUS IS DISCHARGED 20140101 22991231 19000101 22991231 16



7105NURSERY AND NON-NURSERY REVENUE CODES 20140101 22991231 19000101 22991231 16



7106PROVIDER DRG BASE RATE IS ZERO 20140101 22991231 19000101 22991231 16



7107PROVIDER DRG COST TO CHARGE RATIO IS ZERO 20140101 22991231 19000101 22991231 16



7110DRG AGE THRESHOLD NOT ON FILE OR ZERO 20140101 22991231 19000101 22991231 16




Checkwrite End Date



7111DRG OUTLIER THRESHOLD NOT ON FILE OR ZERO 20140101 22991231 19000101 22991231 16



7112DRG MARGINAL COST PERCENT NOT ON FILE OR ZERO 20140101 22991231 19000101 22991231 16



7115DRG INVALID PRINCIPAL DIAGNOSIS 20140101 22991231 19000101 22991231 16



7116DRG CODE COULD NOT BE DETERMINED 20140101 22991231 19000101 22991231 16



7117 DRG INVALID RECIPIENT AGE 20140101 22991231 19000101 22991231 16




Checkwrite End Date



7118 DRG INVALID RECIPIENT GENDER 20140101 22991231 19000101 22991231 16



7119 DRG INVALID DISCHARGE STATUS 20140101 22991231 19000101 22991231 16



7120 DRG INVALID BIRTH WEIGHT 20140101 22991231 19000101 22991231 16



7121DRG GESTATIONAL AGE AND BIRTH WEIGHT CONFLICT 20140101 22991231 19000101 22991231 16



7122 DRG CODE NOT ON FILE 20140101 22991231 19000101 22991231 16




Checkwrite End Date



7123 DRG CODE ON REVIEW 20140101 22991231 19000101 22991231 16



7124 DRG CODE NOT ON RATE FILE 20140101 22991231 19000101 22991231 16



7125 DRG INITIALIZATION FAILED 20120101 22991231 19000101 22991231 16



7126SUPPLEMENTAL PYMT PERCENT NOT ON FILE 20140101 22991231 19000101 22991231 16



7127PROVIDER MISSING FROM DRG RATE TABLE 20140101 22991231 19000101 22991231 16




Checkwrite End Date



7128DRG - MAJOR DIAGNOSTIC CATEGORY NOT ON FILE 20140101 22991231 19000101 22991231 16



7129DAY OUTLIER THRESHOLD NOT ON FILE 20150715 22991231 19000101 22991231 16



7130DAY OUTLIER PER DIEM AMOUNT NOT ON FILE 20150715 22991231 19000101 22991231 16



7503CONFLICT CODE ON RESPONSE CLAIM DOES NOT MATCH 20150715 22991231 19000101 22991231 175 Prescription is incomplete.

8006

PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO MISCELLANEOUS ERROR. 20151204 22991231 19000101 22991231 45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. MA67 Correction to a prior claim.

8007

PROVIDER REQUESTED CLAIM ADJUSTMENT DUE TO BILLING ERROR. 20151204 22991231 19000101 22991231 45


8076PROVIDER SENT REFUND DUE TO PATIENT LIABILITY PROCES 20151204 22991231 19000101 22991231 45


8097AGENCY REQUESTED REFUND DUE TO OTHER INSURANCE 20151204 22991231 19000101 22991231 45


8128AGENCY INITIATED OFFSET DUE TO MEDICARE 20151204 22991231 19000101 22991231 45


8134

AGENCY INITIATED OFFSET DUE TO MISCELLANEOUS OR UNSPECIFIED ERROR 20150715 22991231 19000101 22991231 96


8136HPE INITIATED ADJUSTMENTS DUE TO PROCESSING ERROR 20151204 22991231 19000101 22991231 45



Checkwrite End Date



8140

AGENCY INITIATED OFFSET OF OUT-PATIENT CLAIM DUE TO PAID IN-PATIENT CLAIM 20151204 22991231 19000101 22991231 45


8168AGENCY INITIATED ADJUSTMENT DUE TO RATE CHANGE 20151204 22991231 19000101 22991231 45


8169AGENCY INITIATED ADJUSTMENT DUE TO SYSTEM CHANGES. 20151204 22991231 19000101 22991231 45


8170AGENCY INITIATED ADJUSTMENT DUE TO DISPENSING FEE CHANGE 20160721 22991231 19000101 22991231 45


8184MASS ADJUSTMENT - PROCEDURE CODE RATE CHANGE 20151204 22991231 19000101 22991231 45


8187MASS ADJUSTMENT - OTHER REQUEST 20151204 22991231 19000101 22991231 45


8188MASS ADJUSTMENT - VOID TRANSACTIONS 20150725 22991231 19000101 22991231 45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

8190

MASS ADJUSTMENT - VOID TRANSACTIONS - WARRANT CANCELLED 20150725 22991231 19000101 22991231 45


8191MASS ADJUSTMENT - VOID TRANSACTIONS OTHER REQUEST 20150725 22991231 19000101 22991231 45


8199

MASS ADJUSTMENT - VOID TRANSACTIONS IDENTIFIED BY EXTERNAL ENTITY 20151204 22991231 19000101 22991231 45


8200 CORRECTION TO A PRIOR CLAIM 20151204 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. MA67 Correction to a prior claim.

8201 DUPLICATE PAYMENT 20150715 22991231 19000101 22991231 18


8202 CLAIM BILLED IN ERROR 20151204 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. MA67 Correction to a prior claim.

8203 BILLED UNDER WRONG RECIPIENT 20150715 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA36 Missing/incomplete/invalid patient name.

8204PRIMARY INSURANCE PAYMENT RECEIVED 20151204 22991231 19000101 22991231 45


8205 PROVIDER TO REBILL 20151204 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. MA67 Correction to a prior claim.

8206 DUE TO MEDICARE PRIMARY 20151204 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. MA67 Correction to a prior claim.


Checkwrite End Date



8207 RECOUPMENT OTHER 20151204 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. MA67 Correction to a prior claim.

8208NCCI REDETERMINIATION - HISTORY VOID 20151204 22991231 19000101 22991231 97


8209NCCI ADMINISTRATIVE REVIEW - HISTORY VOID 20151204 22991231 19000101 22991231 97


8210 WORKER'S COMP - PROVIDER 20150715 22991231 19000101 22991231 19This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

8211 WORKER'S COMP - RECIPIENT 20150715 22991231 19000101 22991231 19This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

8216 TPL ERROR 20150725 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

8217DUE TO MISCELLANEOUS OR UNSPECIFIED REASON 20150725 22991231 19000101 22991231 45


8220 FULL REFUND 20151204 22991231 19000101 22991231 23Payment adjusted because charges have been paid by another payer.

8221 PARTIAL REFUND 20151204 22991231 19000101 22991231 23Payment adjusted because charges have been paid by another payer.

8227 CAPITATION - EPSDT CLAIM 20150725 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

8229 CAPITATION - FAMILY PLANNING 20150715 22991231 19000101 22991231 97


8235AGENCY INITIATED OFFSET DUE TO THIRD PARTY COVERAGE 20151204 22991231 19000101 22991231 88

Adjustment amount represents collection against receivable created in prior overpayment.

8241ADJUSTMENT GENERATED DUE TO CHANGE IN PATIENT LIABILITY 20150725 22991231 19000101 22991231 45


8242ADJUSTMENT GENERATED DUE TO RATE CHANGE 20150725 22991231 19000101 22991231 45


8243ADJUSTMENT GENERATED DUE TO RECIPIENT DATE OF DEATH 20151204 22991231 19000101 22991231 13 The date of death precedes the date of service. MA67 Correction to a prior claim.

8247ADJUSTMENT GENERATED DUE TO DRG PROVIDER RATE CHANGE 20150725 22991231 19000101 22991231 45



Checkwrite End Date



8248ADJUSTMENT GENERATED DUE TO RECIPIENT RCO ASSIGNMENT 20150725 22991231 19000101 22991231 96


8251

HPE INITIATED VOID DUE TO CHANGE IN PROVIDER ID OR SERVICE LOCATION INFORMATION 20150715 22991231 19000101 22991231 16


MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER ADDRESS.

8299

ADJUSTMENT TO CROSSOVER PAID PRIOR TO AIM IMPLEMENTATION DATE. THIS CLAIM HAS 20151204 22991231 19000101 22991231 45


8454

THIS ACCOUNTS RECEIVABLE WAS ESTABLISHED FOR THE WRONG AMOUNT. WE HAVE MADE COR 20150715 22991231 19000101 22991231 96


8515

THIS CLAIM HAS BEEN DENIED DUE TO A POS REVERSAL TRANSACTION. 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

8516THIS CLAIM DENIED DUE TO A PROVIDER VOID REQUEST. 20151204 22991231 19000101 22991231 45


8517

THIS CLAIM ADJUSTMENT DUE TO A PROVIDER SUBMITTED REQUEST 20151204 22991231 19000101 22991231 45


8550THIS SERVICE IS NOT COVERED BY MEDICAID 20151204 22991231 19000101 22991231 96

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. N643

The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule.

8552

THIS DRUG IS CURRENTLY ON THE ALABAMA MEDICAID PHYSICIAN DRUG LIST (APPENDIX H) 20150715 22991231 19000101 22991231 16




Checkwrite End Date



8553

THIS SERVICE REQUIRES THE USE OF A MODIFIER TO INDICATE ANATOMICAL SITE, DISTIN 20150715 22991231 19000101 22991231 4

The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA130

Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

8554NCCI REDETERMINIATION - APPROVED 20151204 22991231 19000101 22991231 59

Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA91

This determination is the result of the appeal you filed.

8555NCCI REDETERMINIATION - DENIED - NO APPEAL 20160501 22991231 19000101 22991231 50


Documentation does not support that the services rendered were medically necessary.

8556NCCI REDETERMINIATION - DENIED 20160501 22991231 19000101 22991231 50



8557NCCI ADMINISTRATIVE REVIEW - APPROVED 20151204 22991231 19000101 22991231 59

Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA91

This determination is the result of the appeal you filed.

8558NCCI ADMINISTRATIVE REVIEW - DENIED 20160501 22991231 19000101 22991231 50



8560

PAPER CLAIM AND OPERATIVE NOTE REQUIRED FOR PAYMENT DECISION. PLEASE RESUBMIT. 20150715 22991231 19000101 22991231 163

Attachment/other documentation referenced on the claim was not received. N678

Missing post-operative images/visual field results.

8985

AN AUDIT ADJUSTMENT WAS CREATED RELATED TO THIS CLAIM TO RECOUP AN OVERPAYMENT 20150715 22991231 19000101 22991231 96


8986CLAIM ADJUSTMENT PAID BASED ON ORIGINAL CLAIM. 20150715 22991231 19000101 22991231 96


8987

CLAIM ADJUSTMENT PAID BASED ON RECIPIENT ELIGIBILITY IN EFFECT AT THE TIME THE 20160501 22991231 19000101 22991231 272 Coverage/program guidelines were not met.

8989AGENCY INITIATED OFFSET DUE TO MEDICARE 20151204 22991231 19000101 22991231 45



Checkwrite End Date



8991

SYSTEM ERROR - DETAIL MEDICARE AMOUNTS. A SYSTEM ERROR RESULTED IN THE DELETI 20151204 22991231 19000101 22991231 16

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

8993

CLAIM MODIFIED POST-PROCESSING. PERFORMING PROVIDER RESTORED TO SUBMITTED VALU 20150715 22991231 19000101 22991231 B7


8995

CLAIM MODIFIED POST-PROCESSING. BILLING PROVIDER OVERRIDDEN TO FORCE CLAIM TO 20151204 22991231 19000101 22991231 45


8996 PATIENT LIABILITY REPROCESSING 20151204 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. MA67 Correction to a prior claim.

8997

CLAIM MODIFIED POST-PROCESSING. THE BILLED AMOUNT WAS CHANGED TO ZERO ON THE E 20151204 22991231 19000101 22991231 125

Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. M79 Missing/incomplete/invalid charge.

8999CLAIM HAS BEEN SUPER-SUSPENDED. 20151204 22991231 19000101 22991231 133 The disposition of this claim/service is pending further review.

9001

REIMBURSEMENT REDUCED BY THE RECIPIENT'S CO-PAYMENT AMOUNT. 20151002 22991231 19000101 22991231 3 Co-payment Amount

9003NO PAYMENT MADE-TPL IS MORE THAN THE ALLOWED AMOUNT. 20151002 22991231 19000101 22991231 23

Payment adjusted because charges have been paid by another payer.

9500

COVERED DAYS ON THIS CLAIM HAVE BEEN SYSTEMATICALLY REDUCED TO MEET THE ALLOWED 20151204 22991231 19000101 22991231 45


9501PRICING ADJUSTMENT - MEDICARE IP PRICING APPLIED 20151204 22991231 19000101 22991231 45


9502

PRICING ADJUSTMENT - MEDICARE PART B HEADER PRICING APPLIED 20151204 22991231 19000101 22991231 45


9503

PRICING ADJUSTMENT - MEDICARE HEADER PRICING APPLIED 20151204 22991231 19000101 22991231 45


9504

PRICING ADJUSTMENT - MEDICARE HEADER COINSURANCE + DEDUCTIBLE PRICING APPLIED 20151204 22991231 19000101 22991231 45



Checkwrite End Date



9505

PRICING ADJUSTMENT - MEDICARE LONG TERM CARE PRICING APPLIED 20151204 22991231 19000101 22991231 45


9506

PRICING ADJUSTMENT - MEDICARE DETAIL COINSURANCE + DEDUCTIBLE PRICING APPLIED 20151204 22991231 19000101 22991231 45


9507

PRICING ADJUSTMENT - MEDICARE PART B DETAIL 1 PRICING APPLIED 20151204 22991231 19000101 22991231 45


9508

PRICING ADJUSTMENT - MEDICARE PART B DETAIL 2 PRICING APPLIED 20151204 22991231 19000101 22991231 45


9601DAYS COVERED ADJUSTED FOR ES/EMERG DELIVERY 20120101 22991231 19000101 22991231 A1 Claim/Service denied. M46

Missing/incomplete/invalid occurrence span code(s).

9602DAYS COVERED ADJUSTED FOR EMERG DAY LIMIT 20120101 22991231 19000101 22991231 A1 Claim/Service denied. M46


9603DAYS COVERED ADJUSTED FOR MEDICARE DAYS LIMIT MET 20120101 22991231 19000101 22991231 A1 Claim/Service denied. M46


9604DAYS COVERED ADJUSTED FOR PARTIAL ELIGIBILITY 20120101 22991231 19000101 22991231 A1 Claim/Service denied. M46


9800CUTBACK - CLAIM PROCESSED AS AN ENCOUNTER. 20151204 22991231 19000101 22991231 45


9907 TPL AMOUNT APPLIED 20151204 22991231 19000101 22991231 23Payment adjusted because charges have been paid by another payer.

9908PRICING ADJUSTMENT - PHARMACY PRICING APPLIED 20150725 22991231 19000101 22991231 45


9910PHARMACY DISPENSING FEE APPLIED 20151204 22991231 19000101 22991231 91 Dispensing fee adjustment.

9911PRICING ADJUSTMENT - LONG TERM CARE PRICING APPLIED 20150725 22991231 19000101 22991231 45


9913FQHC RCO PAID AMOUNT ADJUSTMENT 20150715 22991231 19000101 22991231 16



9914PRICING ADJUSTMENT - REV FEE PRICING APPLIED 20151204 22991231 19000101 22991231 45


9916PRICING ADJUSTMENT - UCC RATE PRICING APPLIED 20150725 22991231 19000101 22991231 45


9918PRICING ADJUSTMENT - MAX FEE PRICING APPLIED 20150725 22991231 19000101 22991231 45


9919PRICING ADJUSTMENT - PROVIDER LOC PRICING APPLIED 20150725 22991231 19000101 22991231 45



Checkwrite End Date



9920PRICING ADJUSTMENT - ZERO PRICING APPLIED 20151204 22991231 19000101 22991231 45


9921PRICING ADJUSTMENT - PA PRICING APPLIED 20150725 22991231 19000101 22991231 45


9922PAYMENT REDUCED DUE TO PATIENT LIABILITY DEDUCTION. 20151204 22991231 19000101 22991231 142 Claim adjusted by the monthly Medicaid patient liability amount.

9926 CLAIM HAS CUTBACK AMOUNT 20150725 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

9928PRICING ADJUSTMENT - DRG PRICING APPLIED 20120101 22991231 19000101 22991231 A1 Claim/Service denied. M46


9929PRICING ADJUSTMENT - RCO HDR PAID PRICING APPLIED 20150715 22991231 19000101 22991231 45


9930

PRICING ADJUSTMENT - ENCOUNTER RATE PRICING APPLIED 20150725 22991231 19000101 22991231 45


9931

PRICING ADJUSTMENT - ENCOUNTER PAID AMOUNT APPLIED 20150715 22991231 19000101 22991231 45


9932PRICING ADJUSTMENT - HOSPICE PRICING APPLIED 20150715 22991231 19000101 22991231 45


9933 HOSPICE ENHANCED DAYS PAID 20150715 22991231 19000101 22991231 45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

9935PRICING ADJUSTMENT - MAX FLAT FEE PRICING APPLIED 20150725 22991231 19000101 22991231 45


9936 PRICING ADJUSTMENT - TPL PAYER PRICING APPLIED 20151204 22991231 19000101 22991231 23

Payment adjusted because charges have been paid by another payer.

9990CLAIM DENIED. CORRECT AND RESUBMIT. 20151204 22991231 19000101 22991231 A1 Claim/Service denied. N59


9998

CLAIM WAS PRICED IN ACCORDANCE WITH MEDICAID POLICY 20150725 22991231 19000101 22991231 45



9998

CLAIM WAS PRICED IN ACCORDANCE WITH MEDICAID POLICY 20150725 22991231 19000101 22991231 45



9999PROCESSED PER MEDICAID POLICY 20150725 22991231 19000101 22991231 45


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